Give what the customer wants? Urinary stone removal + spay packaged deal

A female Miniature Schnauzer has been passing blood in the urine and an X-ray showed several large bladder stones. The couple, in their late 40s, wanted a spay and bladder stone removal packaged deal as this would be cheaper.

Sometimes it is possible to provide such a deal. For example, dental scaling and vaccination or spay and vaccination. However, in this case, it is still possible to do what the customer wants. Make a longer incision, do the spay first. Then open up the bladder and remove the stones.

However, the two surgical procedures will take a much longer time. "There may be complications of bleeding, infection and death on the operation table," I advised the owner against doing this. No news from them since two weeks ago.

Shouldn't I be more flexible and close the deal?  Give what the customer wants? In the interest of the dog, I don't do two-in-one surgeries lasting over one hour. The longer the procedure, the higher the chanes of complications like bleeding, infection and death. But other vets do not agree and some customers can be lost just by sticking to this policy. The younger generation in their 20s now may be better educated and more sophisticated to accept my advices. 

1004. Update on old Beagle with bladder cancer

DR SING'S TRUST & AUDIT PROCESS OF A BLADDER CANCER CASE AT TOA PAYOH VETS


998. Sunday's interesting case. An old Beagle drips lots of reddish brown urine



Sunday May 13, 2012



I was at the Surgery in the morning and saw a large amount of reddish brown urine drops in the waiting and consultation room. Dr Daniel was consulting with the owners and Mr Min was mopping the floor a few times. If I were Dr Daniel, I would restrain the dog on the consultation table but each vet does his own thing and so this situation led to bloody urine every where. I mean, if the waiting room was full, the other clients would be most unhappy trying to avoid stepping on bloodied urine on the floor in a small waiting room of Toa Payoh Vets.



This is what I mean by "common sense" in a vet who handles a case.  Restrict the dog's movement or crate him. I did my trust and audit in this case handled by Dr Daniel to improve the process of consultation and consistency of practice.



The X-ray showed around 6 small radio-opaque stones of around 4 mm x 6 mm and other sizes. Dr Daniel said were unlikely to cause so much bladder bleeding. Each vet has his own opinion and so that is life.



(May 19, 2012 - RETROSPECTIVE REVIEW - Dog had been operated by me and had a large adenocarcinoma of the bladder. The blood clots were dark red black and green and were from the degenerating cancerous cells of the adenocarcinoma)





I disagreed with him as there was one stone with a sharp edge, like a dagger.  This sharp stone swished about inside the bladder would have stabbed the bladder mucosa and cause bleeding. "This is not chronic cystitis," Dr Daniel disagreed with me. "The blood in the urine occurred only 2 weeks ago." This was a difference of opinion.



(May 19, 2012 - RETROSPECTIVE REVIEW - Dog had been operated by me and had a large adenocarcinoma of the bladder)



An old Beagle. Likely to be a bladder carcinoma as well.  Dr Daniel advised ultrasound and surgery with high anaesthetic risks of death on the op table. Since the dog's red blood cells were low, his opinion was that this dog would not survive the operation. So what to do? The consultation took more than 30 minutes and he was still talking.



(May 19, 2012 review. In my opinion, ultrasound adds to cost and will not help to resolve this dog's problem. The newly graduated vet has been taught by the professors to go for more and more tests to confirm a diagnosis of cancer. In practice, he must know what to do in an old dog with cancer, not asking for more tests as many owners prefer to have lower veterinary costs. In this case, blood and urine tests and an X-ray of one view had been done. The X-ray was average quality and an air-contrast X-ray of the bladder would be preferred)



I intervened by entering the consultation room which had a bloodied floor now. I said to the couple: "Basically, you have two options. Consent to an operation and know the high risks and get the stones removed. If there is cancer of the bladder, give us consent to euthanase the dog during surgery. The other option is to medicate and euthanase the dog when the drugs don't work as she is suffering from pain and incontinence. In the meantime, get the dog on the IV drip, painkillers and antibiotics for at least one day and before surgery."



Vets can't afford the luxury of time on a busy Sunday morning to handle a case for more than 30 minutes unless it is necessary. Other clients have to wait a longer time. Owners of hospitalised dogs need to be called. The sick dogs need to be checked and there are many things to do. So, it is not possible to keep on talking while the old Beagle keeps on dripping.



In any case, the pressures of having to provide affordable veterinary costs v. high overheads of operating expenses and increase government regulatory payments mean that not much time can be spent on having long consultations per owner. All employee and associate vets have to be aware of the high financial aspects of running a veterinary surgery and not just how much they get paid.



SURGERY DONE BY ME

The longer the surgical procedure, the higher the possibility of complications of death on the operating table. I told Dr Daniel and the owner that I would be operating on this high risk old dog with seizures. The wife did not want euthanasia even if an inoperable cancer was found. There was an inoperable cancer in the bladder. I excised as much as I could of the cancer.



As at May 18, 2012, the dog was eating and had peed clearer urine. I had not expected this old dog with seizures to survive a 2-hour surgery. Dr Daniel was collaborating with me while I operated to excise the tumour near the neck of the bladder. There was no way I could complete such a bladder cancer excision in 30 minutes. The couple took the high risks to consent to an operation. It was a surprise to me that this dog survived.



DETAILS OF SURGICAL PROCEDURES ARE BELOW:

5297 - 5303.

Bladder cancer surgery in an old Beagle

Proper pre-surgical treatment and planning gave this old dog the best chance of survival on the operating table. It is not a given that all old dogs will survive as many of them have poor health.


UPDATES AND MORE IMAGES ARE AT:
http://www.sinpets.com/dogs/20120440veterinary-audit-cystotomy-carcinoma-bladder-toapayohvets-singapore_ToaPayohVets.htm

Planning for the bladder cancer surgery - The Beagle

As Dr Daniel was handling the case, he had a long chat with the couple. X-ray revealed 6 small pieces of stone but the blood test showed red blood cells being low. The dog was bleeding from the bladder. He advised ultrasound.

1002. Walking the talk to be the top 5 veterinary surgery in Singapore

Walking the talk On Thursday, May 17, 2012, 12 noon, I had a meeting with Dr Vanessa and Dr Daniel, both facing me with serious faces across the consultation table. A client came but I asked her to wait.  My management meetings do get interrupted and the train of thoughts get de-railed and so I ask some clients to wait a while and keep my talk short and sharp. Walking the talk to make Toa Payoh Vets the top 5 veterinary surgery in Singapore is an uphill task, requiring frequent checks and balances on the staff performances. For this meeting, I got a big book and recorded down the meeting points. 1. Strategy.  Being the top 5 veterinary surgery in Singapore. I said: "It is easy to talk about my vision of Toa Payoh Vets being the top 5, especially in veterinary surgery. Talk is cheap. Talk is easy. I have implemented certain checks on your work and you may not like my frankness in pointing out deficiencies. But this is part of management and part of continuing education. 2. "Keeping meticulous records is part of this vision. How can Toa Payoh Vets be the top 5 if its vets don't keep meticulous records?"  I illustrated a case of a vet's sedation of a Beagle with the bladder tumour which was a "trust and audit" case done by me to check on the standard of care. The injection given was 30% of Dom and Ket as instructed by me and was injected. The dog was old, had fits, low red blood cell count and was dribbling bloodied urine. The figure written was 50% as no amendment was made.  "Meticulous records in anaesthesia and surgery provide a strong defence in the case of litigation," I said. "There will be more litigation and complaints as Singaporeans get more educated and demanding. So, meticulous recording by the vet provides a strong defence. I will be printing serial number record books soon and the operating vet will be personally responsible." 3. Keeping associate vets happy so that they will stay with Toa Payoh Vets. The vet is the prime mover but that does not mean that he or she can order any drug he or she likes and not be aware of the high costs. "Keeping the associate vet happy does not guarantee his or her loyalty to Toa Payoh Vets," I had said privately to Dr Daniel. "With sufficient clientele and easy access to money from parents or joint start ups with another vet, I don't expect associate vets to stay long and be loyal to Toa Payoh Vets. "We have a few cases where the rich parents finance the start up of new vet practices. No sweat for the younger vets as regards the need to earn sufficiently before opening because the money is already provided by the parents." 4. Leaving a legacy for the 2nd generation. I have stated to my associate vets, Dr Vanessa and Dr Jason that I do not build up Toa Payoh Vets for Dr Daniel or the second generation. I will just sell off the practice and retire when I am unable to practise. I don't worry about legacy. If the 2nd generation can't perform, so be it. In any case, the Toa Payoh Vets will just decline as there will be more intense competition over the years. The practice will die off as excellent performance counts a lot in a vet practice as referrals come in from other parts of Singapore. "The Beagle with the bladder tumour (Trust & Audit in a Case of an old dog with fits and bladder cancer) was from Pasir Ris and the Shih Tzu with the crusty scabies ears  (No Smoke Without Fire - No Scabies Without Mites) was from Jurong East. So, there must be some reasons they come to Toa Payoh Vets when there are other vet practices conveniently nearby." I said to Dr D and Dr V as these two cases were handled by me. There are around 45 vet practices in Singapore and there will be at least one near Pasir Ris and Jurong East and the majority of Singaporean pet owners will go to the vet based on proximity.  5. USP. "One Unique Selling Proposition" of Toa Payoh Vets is that there is no need to come back for stitch removal," I said. "Yet Dr Vanessa asks clients of spayed and neutered dogs to come back in 14 days' time." There is a need to be consistent in veterinary surgery amongst the vets here." I said. 6. There were other issues such as vet cost and the vets gave their feedback. "Ultimately, in a corporate world, associate vets have to take instructions from the superior or boss. If not, they better open their own practice, order expensive drugs they like and do consultations of half an hour per average case." There is a need to provide affordable vet costs and reduce waiting time. Obviously if the associate vet spends half an hour per case and keep the others waiting 2 hours, there will be much dissatisfaction in many others as Singaporeans are time-pressed. In conclusion, real world business needs to be profitable. Otherwise, associate vets will get lesser pay and will just go to another practice. As simple as that. A happy working environment with poor profits will not retain any associate vet even if the management makes them happy at work. There is the bottom line and the need to recover a decent return on investment for the founder too. Many vets don't know how to do the financial analysis. A high revenue with high expenses does not mean that the business is making money! Same for the government running a country. Webpage: http://www.bekindtopets.com/dogs/20120521walking-the-talk-to-be-top-5-vet-surgery-singapore-ToaPayohVets.htm

1001. Follow up on the "panting dog"

Update on May 18, 2012. The old dog suffered from severe ascites and was in pain. Euthanasia was the humane option and was done 4 days ago.




HISTORY

On Wed, Apr 25, 2012 at 10:31 AM, .... wrote: Dear Mdm

I would like to make an enquiry about my dog (Schnauzer-cross). She is 15 years old.
We brought her to the vet as she was panting heavily and her stomach swelled and keeps hiding in the room, away from the rest of the family.
X-ray results shows that she has an enlarged liver. Also, the blood test shows that she has high Calcium, high platelets and white blood cells.
Most likely, says the vet, my dog has cancer and recommended an ultrasound at its hospital. Meanwhile, the vet has given her some liver medication and my dog's condition has improved though the vet did share that this would be temporary.
I am worried about the costs of sending my dog to their hospital as I did some research and found that the hospital tend to order several tests and cost of the treatment usually escalates. If she is found to have cancer, it's likely that we will not opt for treatment as she is old and already her quality of life is poor, with poor eyesight etc.
Does your clinic offer ultrasound services and how much does it cost? Is ultrasound the best option for my dog now?
My family wants to see her pass on without suffering too much. What should I do to alleviate her suffering?
I would really appreciate if you could advise me. Please feel free to call me if need be.

Rgds





E-MAIL REPLY FROM DR SING DATED APR 26, 2012

26/04/12 03:35 PM

cc Subject Re: Enquiry about ultrasound costs

I am Dr Sing from Toa Payoh Vets. We spoke by phone today Apr 26, 2012, 3.31 pm and the following is my brief reply to you:

 
In my opinion, the important health care issues in your old dog are:
1. what is the cause of "panting heavily" and "swollen stomach"
2. what is the cause of the "high platelet and white blood cell count"

Is there liver cancer or not? Is there a cure?  If the cause of the illness is known and treatment can be effective, it should not be "panting heavily".


 E-MAIL TO DR SING DATED MAY 14, 2012









Hi Dr Sing

Just wanted to thank you for all your help — calling me back when I wrote to you, treating .... during her last days and calling to check on how she was doing.

Also, I didn't get to share with you that I am glad to have chanced upon your website — it's very informative and lets pet owners out there see that your practice does very good work and that you are sharing your knowledge with younger doctors.
Thanks again — I really appreciate all that you've done.


Rgds



E-MAIL REPLY FROM DR SING DATED MAY 18, 2012


Just read your email of 4 days old. Thank you very much for your kind comments.Sharing real case studies via the internet takes up a lot of time to document each case. However, real cases will benefit the animals more, as their owners become educated on real life cases. Vet students struggling in their little rooms to pass exam can remember their studies better when they see the real case pictures, bringing vet medicine and surgery alive to them.

The practice of veterinary medicine and surgery of so many animals other than dogs and cats is so large in scope unlike human medicine (one species - homo sapiens) such that it can be overwhelming and frightening to the younger vet, as the owner expects the vet to "know it all."   

Best wishes

1000. Follow up: No smoke without fire - No scabies without mite

I phoned the owner today, May 16, 2012 to enquire about the female shih tzu, one year old with only one scabies mite shown in the microscope to her. The friend had the sibling but its ears were the only area affected.

"A scratch or two, short while in the morning and evening," she said. "Not like the furious scratching earlier. Do I have to consult you 2 weeks later?"

"No, if the hairs grow back," I said. "Some scabies dog need a 2nd injection 2 weeks later. Wait and see." I was glad that the ivermectin injection had worked and the owner had bathed the dog's skin lesions thoroughly. It was very stressful for her to see her young dog scratching for weeks."


Blood test was taken on May 14, 2012 as the dog had generalised chronic skin infections.
"Normal blood test results, except for increased liver enzymes," one vet told me.

RESULTS are normal for the total white cell count but if you analyse the cell types, you will see that this dog has a chronic infection as evident by increase in monocytes to 11% and eosinophils to 8%. Normally the values are below 2%.

Total WCC  11.9 (6-17)

Neutrophils  71%      8.47 absolute
Lymphocytes 10%    1.15
Monocytes    11%    1.27
Eosinophils   8%       0.96
Basophils      0.3%    0.04

LIVER PROFILE
SGPT/ALT     95  (<59)
SGOT/AST   158  (<81)

Did the owner's mother use medication on the skin over the past months, affecting the liver?
Overall, this has been a chronic skin disease for a young puppy. Was it ringworm first, yeasts inside the ears and then scabies spreading from ear edges to face and paws? Or was there scabies in the first place? It is hard to say. Blood tests can be useful and in this case, there was no bacterial infection as Vet 1 had given the antibiotics. Antibiotics don't kill scabies mites and that was why the dog kept being itchy and worrying the lady with reddened eyes.    

999. No smoke without fire: No scabies with mites

"My dog scratches her face vigorously, non-stop last night," the lady with red eyes showed me a young Shih Tzu with bright red cheek, ear and eye areas. "Is she suffering from an allergy?" Her friend had brought her in to Toa Payoh Vets on this fine Saturday morning, May 12, 2012.

I was present from 9 am as I was conducting a "trust and audit" process on Dr Jason Teo. This is part of effective management of a licensse to ensure a high standard of veterinary care and to rectify errors and ommissions of the practice.

"I remember your case," I said to the friend as I fished out the card assuming that the affected dog belonged to the introducer. The lady with the red eyes said: "I just want a second opinion. For the past one and a half week after treatment by Vet 1, my dog is not getting better. She is still very itchy and her skin is full of red sores."

I put the dog on the examination table and viewed the records and medication of Vet 1.
"Most likely, your dog has scabies," I pointed to the crusted lumps on the ear edges. "Just like your friend's dog I treated some 4 weeks ago."
"No," the lady with the red eyes showed me a bottle of an anti-fungal liquid medication which stated "for cats",  an ear drop bottle and an enzyme-based shampoo. "Vet 1 had written in the case sheet - no sarcoptic or demodectic mite seen. She said my dog has malassezia inside the ears." Vet 1 had confirmed by staining."

"It is possible that your dog has malassezia, a yeast infection." I said. "Negative skin scrapings do not mean there are no scabies. After all, your friend's dog, the sibling of this dog, had scabies."

"It is not possible as our dogs don't meet." she said.

"Scabies can be transmitted by owners' hand. Did you touch her dog earlier?"

"Yes, kiss and hugs."

"So your hands could have transmitted scabies mites to your own dog. When did you touch your friend's dog?"

"One to two months ago."
"How is the scabies dog now?" I asked the friend. "Do you remember seeing one scabies mite under the microscope?"
"Yes," the friend said. "My dog is fully cured now. I complied with all your instructions."
"Normally it will take 2 weeks and one injection to recover," I said.
"My dog recovered in 1 week as the hair grew (back on the ear edges)."

So, now I have to prove that this lady's dog has scabies. I asked Dr Jason and Mr Min to do a few skin scrapings. "Make sure it is deeper. There is no need to use oil. A drop of water will do." So both took the dog back room and produced a skin scraping as the case was Dr Jason. 

I examined the skin scraping. There was no scabies mites.
"I can't find any mite," I said to the lady. "I will have to do a deeper skin scraping to look for the mites." The lady cringed at the thought of drawing more blood from the ear edge skin scraping as she could feel the pain of her young dog.
Dr Jason shook his head when I told him there was no mites seen from the ear crust. "No mites, no scabies." Simple as that. "It could be ear trauma."

Yet the clinical signs of intense itchiness of the face, cheeks and ears over one and a half weeks meant some mites burrowing. The elbows and hocks were reddish and hairless. The backside had several ringworm like patches. So, there was some pathogens. Malassezia and ringworm medication was given and there was no improvement.

"Is the anti-fungal medication bottle that states 'for cats' safe for use in dogs?" the lady with red eyes asked me.
"Well, the liquid medication in the bootle is not produced by the drug company for dogs. So, it is marketed for cats. However,  the dog can take the medication if given appropriate doses."

The problem is that the young female dog is still scratching intensely.

On second thoughts, I reviewed the slide again instead of doing another skin scraping. Hoping against hope.  And there, a fat looking squarish mite was moving his six claws under the slide!
The owner saw it under the higher power. I got the power to the lower one and the mite was distinctly seen.

So, there was proof of scabies.

No smoke with fire. No scabies without scabie mites. I could find only one. But that is sufficient as it is sometimes very difficult to find them. Unless the skin scraping is deeper as the mites burrow under the skin.

Once the diagnosis is there, the treatment is routine. However, this sibling seems to have some systemic disease like hormonal disorder as the whole body is affected, except for the trunk. I needed a blood test and the owner consented. This may not be a simple case of scabies and malassezia. It may be related to a poor immune system or hormonal imbalance like  an early stage of "polycystic ovary syndome."  It is hard to say at this stage as more tests can be expensive. Two siblings. One had scabies only on the ear edges. This one had the whole body infested with skin disease. Why?