The owners were two sisters and were retired nurses whose cat had attended to for the past 16 years.
Nothing heard from them since 2009 when the cat had high kidney enzymes and a kidney prescription diet was recommended by me. But they fed fish as they felt the cat needed more nutrition. The cat thrived. Till now. Blood in the urine appeared when the antibiotics were not given or injected.
Vet 1 did a house call after office hours. The cat scratched the owner.
Vet 2's place was blaring with music after office hours. The cat scratched the nurse.
The reputation preceded her.
Yet when the owners held the cat for blood collection by Dr Daniel Sing, she did not object. "This is surprising," the older sister said. I asked whether the abdomen was palpated for bladder stone or tumour as the cat is very old.
"I don't feel any," Dr D said.
I got the cat out of the cat by asking the sisters to take her out. Unscrewed the top and sides. I lifted the cat out from the open side. The cat hissed. "Didn't like you," the sisters said. I quickly palpated the abdomen. There seemed to be a soft mass in the bladder area, around 2 cm x 2 cm. Could this be a bladder tumour?
"Stones are rare in the female cat," Dr D said. "Vet medicine is full of surprises," I replied. "Female cats do suffer from bladder stones. Only an X-ray or ultrasound will tell." The owners didn't want the tests. So, wait and see. One sister asked Dr D about testing the blood for cancer markers. The test may not be available. This is a 16-year-old cat. We wait for the blood test and urine test results first.
"The meticulous recording of the two sisters ought to be inside the case file" I said to Dr D.
"He had recorded it," the sisters told me. Nothing as good as the original notes of the owners as their observations tell much about the condition.
Wednesday, May 9, 2012
Consent is the best form of defence
"The dog has been passing blood in the stools for 14 days. You don't just give a jab and ask the owner to go home, " I said to Dr Vanessa as the owner wanted treatment on the spot and no hospitalisation for the 13-year-old Beagle X. A gentle giant looking Beagle with a white face. I was also in the consultation room.
Should the old dog die soon, the vet may be sued."
"For negligence," the young lady asked whether the dog had colitis as there was fresh blood in the stools and I had said that the likely area of bleeding would be in the colon. This indicated a young lady with knowledge and the vet must be able to provide the standard of care expected by his peers in such situations.
"Consent is the best form of defence," the young fair lady in her late 20s said.
This case is more a standard and duty of care rather than (informed) consent (to specific treatment
as requested by the owner)," I said. "A dog that had diarrhoea for 14 days resulting in more frequency of diarrhoea and blood loss and loss of appetite is not a simple case of one injection and go home. 5%
Actually I can't figure out where "consent " comes into play in this situation. This must be a lawyer or legally trained owner. Later I saw her studying her book placed on a brown table in the waiting room as she waited for the treatment of IV drip. I had instructed what type of treatment to be given inside the IV.
The 500-ml 5% glucose saline IV drip normally runs over one hour. So, I helped her to take the dog to the father's car. The father would drive the car closer to the front of the clinic. I would hold the drip set and she would carry the dog of 18kg. "Put the dog on the floor of the car," I said as the blood gushed back into the drip set due to the lack of gravity for the drip to flow. The front car seat was pushed forward. She would hold the IV line as high as possible in this small car and the drip droplets flowed again.
FOLLOW UP
I phoned today Day 3. Dr Vanessa had phoned earlier twice. The dog was OK.
"The dog can only be certified OK if he has passed normal stools," I said to Dr V at 2pm. "Due to the spasmogesic drug, he had not passed stools for 2 days. That does not mean he is OK." The lady returned my call at 3.30pm and provided the following feedback:
Day 1. Had diarrhoea for 14 days with increasing frequency of diarrhoea. Dog would drink but pushed away the food. Sought vet treatrment at Toa Payoh Vets. Bundled home with IV drip set in car as the owner did not want to leave the dog in clinic. According to the owner, vomited lst day, diarrhoea for one week 1-2x/day, then more and blood seen. last few days, dia.rrhoea 4-5X
Day 2. No stools. Ate plain rice and chicken.
Day 3. Ate plain rice and chicken. At 3 pm, normal stools passed. First pellet was firm, then semi-soft but no blood.
Blood test - Neutrophils 47%, L=17% but total WBCC normal.
Liver enzymes high.
Stools - Erythrocytes +. No leucocytes, ova, cysts, parasites seen.
Parvovirus test on faeces. Owner did not want it. This was recorded.
Should the old dog die soon, the vet may be sued."
"For negligence," the young lady asked whether the dog had colitis as there was fresh blood in the stools and I had said that the likely area of bleeding would be in the colon. This indicated a young lady with knowledge and the vet must be able to provide the standard of care expected by his peers in such situations.
"Consent is the best form of defence," the young fair lady in her late 20s said.
This case is more a standard and duty of care rather than (informed) consent (to specific treatment
as requested by the owner)," I said. "A dog that had diarrhoea for 14 days resulting in more frequency of diarrhoea and blood loss and loss of appetite is not a simple case of one injection and go home. 5%
Actually I can't figure out where "consent " comes into play in this situation. This must be a lawyer or legally trained owner. Later I saw her studying her book placed on a brown table in the waiting room as she waited for the treatment of IV drip. I had instructed what type of treatment to be given inside the IV.
The 500-ml 5% glucose saline IV drip normally runs over one hour. So, I helped her to take the dog to the father's car. The father would drive the car closer to the front of the clinic. I would hold the drip set and she would carry the dog of 18kg. "Put the dog on the floor of the car," I said as the blood gushed back into the drip set due to the lack of gravity for the drip to flow. The front car seat was pushed forward. She would hold the IV line as high as possible in this small car and the drip droplets flowed again.
FOLLOW UP
I phoned today Day 3. Dr Vanessa had phoned earlier twice. The dog was OK.
"The dog can only be certified OK if he has passed normal stools," I said to Dr V at 2pm. "Due to the spasmogesic drug, he had not passed stools for 2 days. That does not mean he is OK." The lady returned my call at 3.30pm and provided the following feedback:
Day 1. Had diarrhoea for 14 days with increasing frequency of diarrhoea. Dog would drink but pushed away the food. Sought vet treatrment at Toa Payoh Vets. Bundled home with IV drip set in car as the owner did not want to leave the dog in clinic. According to the owner, vomited lst day, diarrhoea for one week 1-2x/day, then more and blood seen. last few days, dia.rrhoea 4-5X
Day 2. No stools. Ate plain rice and chicken.
Day 3. Ate plain rice and chicken. At 3 pm, normal stools passed. First pellet was firm, then semi-soft but no blood.
Blood test - Neutrophils 47%, L=17% but total WBCC normal.
Liver enzymes high.
Stools - Erythrocytes +. No leucocytes, ova, cysts, parasites seen.
Parvovirus test on faeces. Owner did not want it. This was recorded.
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
Tuesday, May 8, 2012
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.
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.
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:
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/.
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/.
Monday, May 7, 2012
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.
"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.
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