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Date:   21 May, 2011  
Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits
 
The wait-and-see client demands an injection in dogs seriously ill 
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date:   21 May, 2011  
toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129
I had two cases in the last 2 days of clients instructing me to give an injection and some medication.

Case 1. Pyometra in a female dog

The woman brought her dog that was not eating and passing smelly vaginal discharge for more than two weeks. Now not eating. Tired. I palpated the swollen abdomen around 4 times and the female Spitz gave up being gentle and started to curl up her lips to warn me not to do it any more. "Just give an injection and some drugs," the woman whose son was my son's classmate instructed me. I suspected closed pyometra which is a life-threatening disease - an infection of the womb.

I still remembered a recent case of the "Vets Who Don't Spay Big Breeds" where the cross bred was euthanased due to poor prognosis. The owners were referred by their vet to a brand-name veterinary practice and could not afford the fees. Much time had been wasted and the dog was no longer standing. Kidneys became infected. As the prognosis was poor, around 40% of survival, the owner decided not to operate and instructed euthanasia. This case quite upset me for this was really a dog that could have been saved if the family vet had tried not to be a one-tracked mind, always referring big breeds to an expensive surgery when his clientele comes from a neighbourhood not in the upper-middle class of Singapore.

Now, this woman demanded an injection. I did not do it as I advised X-rays and blood tests first to aid in the diagnosis of pyometra. She phoned her husband first she said. The husband and I exchanged words over the phone. He then asked his wife to go to another vet.

Case 2. Urethral Obstruction in a male dog
 
In this case, the 14-year old Shih Tzu had passed a lot of blood in the urine and had difficulty peeing for many years. "This is usually urethral obstruction, with stones blocking the urine flow," I said to the woman of over 50 years of age. But the owner said: "Just give my dog an injection and medicine. If the dog still passes blood in the urine, I will come back again. This wait-and-see behaviour is sometimes presented by the owners who don't want to be frugal.  Now, should the vet give what the customer wants? If not, the customer will "think about the advices to do X-ray and blood tests" and then goes to the competitor.  

This is the type of ethical and moral dilemma. The vet can milk the client by doing what she wants. Revenue generated. The dog would have to come back again as the drugs will not work. This is obvious to the vet but the client demands an injection.

I know the medicine will not work and refused to obey her wishes. The woman insisted. So there was an impasse. Other clients in the waiting room watched and listened. 

She exited the waiting room and went outside to phone or consult somebody, probably her family or husband carrying the dog with her. I had asked Dr Vanessa to handle this case but I would keep an eye on this case. 

This was going to be a hot potato if not handled professionally by me as the initial contact for this owner.  This old dog could die due to delay in treatment as he is already 14 years old.

I mean, if I give the injection and medication as requested, I will earn my keep. However, this dog will not recover. The other family members will start to curse the vet for incompetence especially if the dog were to die from renal failure and infection when sent to the competitor and treated belatedly.

The competitor would cover for himself or herself by saying that I should have had done the blood test and the X-ray and give proper treatment early. If that had been done by me, the dog would have been alive. Not just give an injection and some antibiotics. What an incompetent vet!

Well, to make a long story short, the owner agreed to the X-ray which I told her was not necessary if she wanted to save costs on veterinary surgery. She did not believe my diagnosis of urethral obstruction and so she finally agreed to the X-ray.

A surgery by opening the bladder and getting out the urinary stones and pushing back the stones in the penile urethra into the bladder would save some money for the cash-strapped owner. Furthermore, the procrastination is not good for the sick dog as the kidneys may get damaged, inflamed and infected. This is the real world and there is not much the vet can do for the poor dog.

"Suck out all urine," I said to Dr Vanessa as I passed the case for her to follow up. "Do a urine test. This is mandatory. Pump air into the bladder and the stones would be seen clearly." She said: "The cathether cannot be passed into the bladder, so there is a urethra obstruction." Later she told me that another catheter could pass into the bladder. My assistant Min showed me a bottle with around 20 ml of bloodied urine. This would be sent to the Laboratory for urine analysis and a report would be given to the owner later (as part of evidence-based medicine).

The X-ray showed around 5 stones in the os penis and around 3-4 large urinary stones in the urinary bladder. "How you manage this case is up to you," I passed the case to Dr Vanessa as this is one case we would collaborate.

My diagnosis was correct without the need for the X-ray in order to save the owner some money. In some HDB heartland households, any veterinary fees over $50.00 is considered expensive, from my years of practice. However X-rays are a part of evidence-based medicine and give a more convincing proof to the owner as shown below. 

 
14-year-old-male-shih-tzu-difficulty-peeing-for-many-years-toapayohvets-singapore pH=7.0
SG = 1.023
Bacteria - present
Crystal - nil
Red blood cells ++++
White blood cells ++++
X-Ray shows excellent contrast when air has been syringed into the bladder Urine Test from the Laboratory




 

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