982. A vision for Toa Payoh Vets to be top 5 in Singapore

Yesterday, May 8, 2012, I had a long meeting with Dr Vanessa, Dr Daniel and Mr Min as I shared for the first time with them, my vision to make Toa Payoh Vets a top 5 veterinary surgery in Singapore, especially in veterinary surgery.



Three of them sat solemnly across the consultation table in the consultation room with from the left, Dr V, Dr D and Min. A vision from the founder is empty talk if it cannot be properly executed and so I have regular "trust and audit" checks on the veterinary performances and frank talk with the vets and Mr Min. No beating around the bush. No cakes and tea all around as we would be interrupted by in-coming clients and mobile phone ringing.



toa payoh vets, singapore"One vet cannot make Toa Payoh Vets a top 5 veterinary, no matter how clever he or she is," I said. "It is the work of the team to produce the good results in treatment and surgery well done.



"As for you," I said to Dr Vanessa. "When you set up your own practice later, it will be to your benefit if you have had worked in a top 5 veterinary surgery, rather than from the bottom 5," I would zero on her as she does most of the cases.



I had done a "trust and audit" of one of two cases and discussed the results with everyone present. I have practised since I graduated in 1974 and know the work performance of younger vets in the trade, unlike a non-vet founder who may be fooled with lame excuses when performances are not up to expectations.



For example, if a vet tells me he or she can do a cystotomy to remove bladder stones and a neuter in less than 30 minutes and needs to use 3 packets of sutures, I will have serious doubts. Even if it is a cystotomy in a Chihuahua whose bladder is smaller in size than a Miniature Schnauzer. I will use 2 packets at the most.



As for my assistant Mr Min, I advised further on the recording of the hospitalisation record and he would talk about any problems encountered. As regards the amount of food and water consumed, I gave instructions on how they should be monitored consistently. Dr Daniel proposed water to be "ad lib" in the hospitalisation recording as some dogs upturn the water bowls and so no accurate measurement could be done. As for urine output, it would not be possible to measure the exact volume of pee passed out. As for stools, I told Min to record the consistency of whether they are solid or not.



"Do you know what is HR and RR?" I asked Min as he ticked the columns with the HR and RR heading. He is a veterinarian technician. As his English expression is not so good, I asked him again and he mumbled: "The dog is breathing or not."



For some reasons, Dr V burst out laughing. Dr Daniel was serious and that should be the way. It was an contagious laugh and I got infected.



"HR and RR" are beats/minute for the heart and the lungs," I said to Mr Min. As the clinic manager, I have to persevere to set the high standards of veterinary care at Toa Payoh Vets. There will be processes, procedures and protocols set up by me to be adhered to and "audit and trust" checks will be done. There is no other way to be top 5 without any effort and many meetings as each staff has his or her mindset in working.



During this meeting, I instructed that the "inpatient records" with serial numbers be used immediately. Later, I would introduce the "hospitalisation records" with serial numbers. "If cases of negligence litigation," I said. "These records are our defences of the duty and standard of care and each vet will be responsible for his or her records. I will get them scanned and retained for the number of years required."



Presently there are around 45 veterinary practices in Singapore. It takes a lot of my time to supervise my staff work performance but this is needed if I want to build a top 5 veterinary practice in the next 2 years.



Some layout problems with blogger.com
Webpage is at:
http://www.sinpets.com/dogs/20120433standards-of-care-top-5vet-practice-toapayohvets-singapore_ToaPayohVets.htm

981. A total view of the skin disease

"I came to consult you because my neighbour had two poodles and refer me to you," the retired pharmacist told me. "My poodle itches all day long for many months. One injection from Toa Payoh Vets and her dog recovered from the skin problem. So she refers your surgery to me."

Performance counts.

"Please don't imagine that one injection is going to cure all skin diseases," I said. "Do you know whether your neighbour's dog suffers the same skin problem as your 4-year-old poodle?"

Four paws (top and bottom) were heavily licked and crusted with scales. Dry scales below the neck, on both elbows and on hind legs. Both checks crusted with hair loss too. Surprisingly the ear canals were normal. However, there was a 1.0 x 0.8 cm of crusty hair loss on the back of both ear flaps.
This was a very atypical case of sarcoptic mange is it was one. Normally all ear edges are crusted but the ear canals are normal. The face and eyelids and elbow scales and hair loss appeared to be due to another skin mite, demodex. I asked Dr Daniel to do skin scrapings, "Show me what your Murdoch University vet professors have taught you in skin scraping." I said. Dr Vanessa's professor taught her that all skin scapings must have oil so that mites can be seen under the microscope. Actually, it is not necessary to have messy oil soiling the microscope's lens. Mites can also be seen in a drop of water on the slide but then the university professors in Australia never taught their students this method.
So, new crops of students studiously use oil. For example, skin scraping to check for ringworm in hairs can be covered up with a scotch tape. No need oil. But the university professors taught the students that a drop of oil is the best medicine. Unfortunately, some employee vets use many drops and mess up the lens with oil and I have to send the microscope for servicing. Teaching the vet students how to take care of the expensive vet microscopes, operating table and anaesthestic machine is probably not in the Vet professor's scope of lectures.
Back to this case, the skin scrapings were negative for mites and for ringworm.
"What shampoo you use?" Dr Daniel asked the retiree who would rather have nothing to do with this dog as it was his daughter who bought it but was now too busy to care for it.

Some dog shampoos have a drying effect on the dog's skin. But in this case, the sites affected were unusual. The body, under the body and ear flap and canals were normal. A bit of brown anal sac oil. "So what is the cause?" the retiree asked me.

"First of all, you did not want a blood test done. So, I am unable to know the immune status and other health abnormalities affecting the functions of the kidney or liver. Blood tests are important and form part of the evidence-based medicine. Since there is no blood test permitted, it is not easy to rule out many possible causes."

"I understand," the pharmacist said. He had been in the line for over 50 years and know what I am talking about. "But what are the possible causes?"

"In your case, the causes are multi-factorial. Allergy may or may not be one reason. Vice such as self licking of paws due to boredom. Auto-immune diseases, demodectic mange mites, yeast and fungus deeply embeded. No mites seen in the skin scrapings does not mean there are no mites at all."

"A skin biopsy of the paws will be useful as well as a blood test." He was not in favour of that as he had retired. Yet he had two daughters who are working in high positions in the corporate world and they might be able to spare some money for the dog's treatment. But he had not asked them. He was sorry for this poddle scratching the whole day long for months and met a neighour who referred him to the Surgery with the vision of one injection cures all skin diseases.

 "OK, ask your daughter to pay the bill." I presented him the receipt. "It will be best to review 3-4 weeks later." I don't know whether he will come. Skin disease of a chronic nature can be hard to treat and will be more costly. Usually there are many causes. I did not recommend him a special diet or shampoo at this stage as the causes are varied. 

In retrospect, I believe that his dog suffers from demodectic mange but Dr Daniel was not able to show any mites with two skin scrapings. Sometimes, the mites are hard to find. Somethings the scrapings need to be deep till the skin bleeds. Whatever it is, a review in 3-4 weeks is best. Some skin infections do get cured with "one injection" but not this case. The symmetrical presentation of small almost equal areas of skin hair loss behind the back of the ear flaps, on both sides, seem to be a clue that this is an immune-mediated disease. If only, the retiree permitted a blood test. Evidence-based medicine must be practised but within the economic reality of the owner.  
  
 

980. Getting a free ride

May 7, 2012

It was past 8.30 pm but Dr Vanessa and Dr Daniel waited for the cat with pyometra. Usually we close at 8 pm. Three young people brought in a cat saying that they had no money to pay for treatment.  

"The owners were honest," Dr Daniel said to me. "They had stated they had no money. They wanted treatment first and pay later."

"Not even $50 deposit?' I asked. "These are the people who want a free ride. I have a few over the years. I remember distinctly one young couple with a Jack Russell requiring emergency Caesarean. They took the puppies back and never bothered to pay me a cent. There is also presently the owner of one old dog in Toa Payoh Vets. He just would not come for the dog for the last two months and did not pay at all. The dog is still there as you can see. Some owners just would not return calls and I had a cat left in my surgery for over 1 month."

There are such pet owners in Singapore but they are rare. This case of announcing "no money" first is just to let the vets know and if they want to treat, they ought to pay from their own pockets. No more free rides in this case.

Vets are supposed to provide free services, according to some people. But there is a limit to what a non-charity can do. Free consultations and free services can be provided for certain cases but not free rides. Otherwise, the practice goes belly up and becomes bankrupt. It does not mean that when a practice is opened, it is sure to be sustainable and profitable over the years if it is poorly managed, as in all businesses. Nobody cares if it goes bankrupt. Employee vets can always work elsewhere but the one who suffers is the proprietor and the proprietor must set the rules to ensure no financial loss as most employee vets don't care about the maintenance of expensive equipment and order the most expensive drugs they feel is best for their image.           

979. Guinea pig pet shop in Singapore

 

On Sun, May 6, 2012 at 10:12 PM, ...@yahoo.com> wrote:

Dear Judy!
We are moving from Hong Kong to Singapore with our 4 guinea pigs in June and would like to know if you could recommend a good pet store that has Timothy Hay, big cages, pellets and bedding for small animals. Also, do you do check-ups for guinea pigs in case our animals get sick? It looks like you do from the website. Kindly advise. Best,
Patricia

EMAIL REPLY FROM DR SING DATED MAY 8, 2012
 I am Dr Sing from Toa Payoh Vets.
Thank you for your email. Our vets do treat guinea pigs.

One pet shop focused on sales and products of guinea pigs is Pet Gantry at Toa Payoh. Go to their website at
http://www.petsgantry.com/.

978. Follow up Roborovski - scent gland infection?

May 7, 2012 I phoned the owner regarding the scent gland inflammation. The wife answered," Seems to be OK. The left hip area is drying up." That meant there was no more exudate and the two hamsters were separated.

"Can the hamster eat, exercise on the wheel and groom herself?" I asked.
"Yes," she said. "I restrict cycling to 10 minutes as she panted. It could be due to the medication."

The wound drying up. No squeezing by the owner. Good sign of recovery.

977. Bench-marking of a spay procedure at Toa Payoh

Today May 9, 2012, I phoned the father and daughter of the Chihuahua 8 months, Female, I spayed as a benchmark and example to Dr Daniel on May 6, 2012. It is very useful to know the effect of pain-killers and compliance by the owners. On May 6, 2012, Sunday, I spayed Chihuahua, Female, born June 18, 2011, said to be 10 months old. She was 1.7 kg, good bodily condition,38.7 deg C. Vulva slightly enlarged. Bleeding heat said to be 2 months ago. Health check by Dr Daniel, . Hx:. Ab  E/D/T Well. No V+/D+/C/S. PE: BAR, active. heart/lungs normal. GIT normal (abdo palp - no pain). menses 2 months ago. Does not want blood test screening of health. Dom and Ket Sedation at 50% and isoflurane gas maintenance and the dog woke up at the end of last stitch. Ovaries and uterine bodies enlarged and congested as if on heat/infected (see images)/0 absorbable suture x 1 Post op tolfedine + baytril injection SC Home medication 1. tolfedine painkillers x 3 tablets (not given at all). Now Day 3. Advised owner to give. Owner will give crushed tab in banana. 2.  trimeth x 1 bottle, multi-vit x 1 bottle. Owner had given. "Almost all medicine is taken," the father said there was no problem and so did not give the 3 tolfedine pain-killer tablets. Post-op observations by the owner (father) is as follows: Day 1 and Day 2 after op. Not active but can walk to pee and poop as normal. Will eat dry food if the owner added chicken wing meat Day 3 - Not eating since chicken wing meat not added. I advised the owner to continue with chicken wing meat as an eating dog recovers faster. Will give crushed tolfedine powder with bananas as dog like bananas Bandage changes advised but father is afraid the stitches will come off. "No problem with the stitches as they are quite tight," I said. "Wash away the dried blood clots and replace with new bandage on Day 4 or 5. It seems like this spay has no post-op complication despite the owner not giving the tolfedine tablets. But there was a tolfedine and baytril injection post-op. CONCLUSION  Liquid medicine is easier to give in this case. Crushed painkiller tolfedine tablet within meat ball may be advised. The owner said bananas can be used as the dog loves bananas. A follow-up is important after spay but vets usually don't have time to do it and 99% of the cases have no post-op problem anyway. So we don't do it. Bandage changing may be difficult for the owner. lst day is always the inactive day. By Day 3, the female spayed dog should be eating normally. In this case, she was eating when chicken wing meat was added, even on Day 1.The father thought of stopping the chicken wing meat on Day 3 to prevent the Chihuahua from being picky but I advised him not to, till the dog has recovered from surgery, in around 14 days. There is no need for stitch removal in spays done by me and so I doubt I will see this dog from Rivervale in North Singapore again.  Vets veterinary surgery performance. Case study of a Chihuahua spayed by Dr Sing K Y   Sunday May 6, 2012 New client. A young lady with her parents from North Singapore had booked me to spay their Chihuahua. Female, 8 months. Said to have heat 2 months ago. I noted that the vulva was still swollen. I used this case to mentor Dr Daniel so that he could see how an experienced vet would handle a case in the fastest, safest and most efficient way. Veterinary surgery text on spays don't reveal the practical aspects of the real life and death situation.  He was to ask questions about the spay.   1. PRE-OP. 1.1 Inpatient record. General health check up by Dr Daniel. Weight of dog: 1.7kg 1.2 The owner did not want blood test. 1.3 Clipping the surgical area outside the Surgery Room. 1.4 Anaesthesia & surgical record. Dr Daniel to calculate sedation dosage at 50% of the formula for Domitor (0.034 ml) + Ketamine (0.043) IV and add equivalent amount of 0.07 ml normal saline to make it 0.14 ml to be given IV by me. 1.5 Absorbable suture packet 3/0 x 1 was prepared. However, I used 2/0.   2. SURGERY ROOM. 2.1 Sedation by Dr Sing.  Mr Min would hold the dog and distended the left foreleg cephalic vein. He was still not good at this despite his at least one year of experience. Somehow,  he did not press the right elbow skin area and so the cephalic vein was not distended. I tried the IV but found no blood drawn out. I asked him to twist the skin to the side and the cepahlic vein was visible. For some reasons, Mr Min can't distend the cepahlic vein in some dogs but could do in others and today was his bad day.   I knew the dog would not stay still long. So, once I injected and saw the blood gushing inside the syringe, the dog started withdrawing her left foreleg. I injected immediately instead of waiting. There was no time to waste as the full dosage to be given was just 50% of the calculated dose. "The whole dosage might not be injected," I said to Dr Daniel as the dog had withdrawn her leg as I completed the injection. It was a wink of the eye. However, the dog quietened and dropped her head. She was sedated within 60 seconds.   2.2 As 50%* of the formula is insufficient sedation for intubation, I asked Mr Min to give isoflurane gas at 5% for less than 60 seconds. It was around 40 seconds. I intubated the dog. There was slight coughing but soon the dog was anaesthesized and maintained on isoflurane at around 1%. Mr Min was to record the % at 5-minute intervals.   (*At 100% of the formula, no isoflurane gas would be necessary but I seldom use 100% as isoflurane gas is much safer and the dog wakes up at the end of spay. Giving 100% would delay waking up. Each procedure has its pros and cons).   2.3 Dog's belly shaved and cleaned.   2.4 Skin and linea alba incision. In this dog, the umbilical scar was not distinct. So I made the incision a bit further than the usual 1 cm from the scar. I showed how I blunt dissected the subcutaneous fat in less than 2 seconds to show the white fibrous linea alba. Many new vets took longer to find the linea alba due to slow dissection and separation of the fat. Sometimes, the new vet could not see the linea alba due to the cloudiness of the SC fat masking the white line. A piece of SC fat could be cut off if the dog was fat so that the linea alba can be seen..   Then I had to extend cranially to expose the left ovary as the ovary was leaning very close to the cranial edge of the incision without giving me access to the ovarian ligament. "The left ovary is more cranial than the left," I said to Dr Daniel. "I have to extend the incision to expose the whole ovary and the ovarian ligament."     QUESTION. "You didn't break the ovarian ligament of the left ovary," Dr Daniel said as I extended the incision of the linea alba cranially by 3 mm and could ligate the ligament. REPLY. "There is no need to break the ovarian ligament in the Chihuahua if the left ovary is well exposed," I said. "You will note that the right ovary is easily exposed as it is more caudal and I did not need to cut or rupture the ovarian ligament. However, in larger breeds and with small incision, the ovarian ligament can be stretched and cut before ligation of the liagment."   3. The uterine body was ligated once.  4. Linea alba closed with 3 interrupted sutures. 5. Skin incison  (2 cm long) was closed with 2 horizontal mattress sutures. 6. No bleeding but the ovaries and uterine bodies were swollen and red, indicating heat was still present. There was some bleeding of the surrounding tissues due to the dog being on heat. 7. Post-op tolfedine and baytril SC. 4 days of tolfedine. One bottle of trimethoprim and one bottle of multi-vitamin. E-collar and bandage of wound. 8. Dog woke up just as I completed the last stitch as I had asked Mr Min to switch off the isoflurane 1 minute as I stitched the skin.   SUGGESTION. "It is better not to switch off the isoflurane and disconnect in case of emergency," Dr Daniel suggested. ANSWER. "Based on the smooth anaesthesia, such happening is unlikely. However, the endotracheal tube is still inside the dog if there is an emergency." In any emergency, there will be cardiac massage first, in my experience, rather than oxygen.   POST-OP.  The Chihuahua got up without crying within 2 minutes of completion of stitching. This meant I don't need to give Antisedan antidote to reverse Domitor. The surgery took a longer time as I had to extend the cut cranially and to hook out the left uterine horn. In this case, after 6 tries and hooking up the small intestine, I switched to hooking out the right uterine horn and was successful. This delay added up to several seconds. Normally, I could hook out the left uterine horn in 3 attempts. But veterinary surgery is full of surprises. THE ANAESTHESIA AND SURGICAL RECORD                   Weight             Domitor           Ketamine Healthy, young, 10kg        0.4 ml               0.5 ml Healthy, young, 1.7kg       0.068 ml           0.085 ml *Give 50%                           0.034 ml           0.043 ml Actual given  0.03 ml + 0.04 ml = 0.07 ml. Add 0.07 ml normal saline. Total IV = 0.14 ml. A: Injection of induction drugs: 10.45 am B: Isoflurane first given: 10.46 am. Intubated. C: Isoflurane gas stopped: 11.15 am D: First skin incision: 10.54am E: Skin stitching completed: 11.17 am   E-A = 33 minutes E-D = 23 minutes C-B = 29 minutes BENCHMARKING SPAY PROCEDURE The Chihuahua spay surgery by an experienced vet with 40 years of spay experience like me took around 23 minutes in this Chihhuahua. It could be as short as 15 minutes but I don't expect younger vets to achieve this benchmark. However, one hour is too long. TIP:  "The hydraulic operating table must be adjusted to the proper height for the vet to operate comfortably and efficiently," I said to Dr Daniel. Each vet has his or her own height and so it is best not to bend double by not making full use of the hydraulics of Toa Payoh Vets' operating table in long surgeries like spay. QUESTION:  "How is it possible for a spayed dog to bleed on heat when she is spayed?" Dr Daniel asked me when I said that there are complaints of dogs and cats still cycling with heat when they have been spayed. "Usually there is a bit of ovarian tissue left behind," I explained that the left ovary is more cranial. So, a vet may incise a bit of ovarian tissue after ligation of the ovarian ligament. The prevention is to make a bigger linea alba incision to expose the whole ovary and ligament. This means making a big skin cut which cannot be helped. Owners are unhappy when spayed dogs and cats come on heat staining the floor with blood and with cats, continuous caterwauling can drive the owner crazy as evident in one case of a spayed cat. A spay is not that simple after all. Besides being on heat, there are reported cases of stump pyometra. I encountered one such case of a dog spayed by Vet 1, in the last 40 years of practice and that would be due to remnant of ovarian tissues left during spays. All veterinary surgeries will adopt a consistent process and approach as described in this case study. I will be doing my trust and audit of some veterinary surgeries done by my associate vets. In the April 20, 2012, AVA Veterinary Clinic inspection of Toa Payoh Vets, the letter of the annual renewal of the licence mentioned that the clinic was well managed. I intend to ensure that it will be well managed with the trust and audit procedures. It will always be difficult to effect changes for the better and this needs time and explanation.

  

976.  Hamster's neck swelling may or may not be cancerous - E-mail query from Malaysia 

E-MAIL TO DR SING DATED MAY 4, 2012

Dear doctor,

My sister's Syrian hamster (about 2 yr old) is having a neck tumour and both the vets that we consulted advised that it is cancer, and there is nothing that they can do about it. Is there anything that we can do to reduce her suffering to the minimal? For example special diet or anything to watch out. I saw from your blog that you had performed surgery for similar cases too, unfortunately my sister and the hamster reside in Malaysia so we are unable (prohibited) to bring the hamster oversea for your consultation.

Thank you very much

Regards,
X

Sent from my iPad

E-MAIL FROM R SING DATED MAY 4, 2012

If possible, send 2 images if possible. There are no drugs that are effective...

May 5 (2 days ago)

If possible, send 2 images if possible. There are no drugs that are effective against tumours.

E-MAIL TO DR SING DATED MAY 6, 2012

On Sat, May 5, 2012 at 12:22 PM, ...@hotmail.com> wrote:

Dear doc,
I'm X's sister, the owner of the hamster. Attached herewith the pictures of my hamster who suffers from cancer

E-MAIL REPLY FROM DR SING DATED MAY 6, 2012

Thank you for 3 images. Neck swelling is large. Is it hard and firm or soft and cystic? Have you got the vet's report.

It may or may not be cancerous as it is hard to diagnose just by size. In some cases, it may be a haematoma, an abscess or soft tissue growth under the skin. As the hamster is old, cancer is likely but not definitely.

To confirm whether it is cancerous, the swelling has to be sent to the lab for histopathology. Therefore, the diagnosis is based on FNA (fine needle aspiration) of the swelling to be sent to the lab for histopathology.

Surgery by excision is the only option but the anaesthetic risk is much higher. Any medication like pain-killers and antibiotics from your vet can be given but will not resolve the problem.