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Date:   14 June, 2013  
Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits

Against Medical Advices (AMA)
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date:   14 June, 2013 
Be Kind To Pets
Veterinary Education
Project 2010-0129

"Vet 1 did not advise me to get an X-ray to check whether the cause of blood in my dog's urine is due to urinary stones," the owner said to me. I had reviewed Vet 1's medical records of this poodle and Vet 1 had not written his advices to get X-rays done. Earlier, I had asked Vet 1 whether he did advise X-ray since the owner told me he was not told. "I always advise X-ray and urine test when a dog passes blood in the urine," Vet 1 said to me. "The owner wanted to wait and see after a course of antibiotics."

A urine test was done as there was a report which showed "No crystals in the urine." I told the owner that I had written "owner does not want radiography" on the urine test report as I had reviewed this case done by Vet 1 and had asked him why he did not advise X-ray during the consultation. Vet 1 had said that the owner did not wish to have X-ray. However there was no AMA in his medical report and I had not pursued the matter further. I was present when the owner came as his dog had passed blood in the urine after the course of antibiotics. 

Sometimes, I don't record every medical advice to the owners too and this can be held against me when there is a negligence complaint to the authorities or in litigation.

It is one man's word against another. Who to believe? I got the owner's permission to do a blood test, X-ray and urine test. I asked my assistant to use "Whats App" from his mobile phone to send him all the 3 results. The owner replied instantly with queries and this showed that he was much concerned about his old dog's health.

Many old dogs are family members. This case shows that the vet must be proactive and consistent in his veterinary process, protocols and systems to provide evidence-based medicine. Many times we want to save money for the owner by not doing tests. But such kindness could turn against the vet if the dog dies. By recording AMA (Against Medical Advices) in the medical records during consultation, no ambiguity arise when there is litigation or complaint to the vet authorities.

I usually write as I talk to the owner. Some vets do their writing at the end of consultation and this is where he or she forgets to record medical matters and advices. If the owner has been given the X-rays or lab test reports, this should also be written down in the case sheets. 

Nowadays, Singapore owners are more sophisticated, veterinary competition is more intense. Vets have to deliver results or justify their treatment and this can be done by being meticulous and aware of the need to have a proper process, system and protocols in veterinary diagnosis and treatment of diseases in pets. This case illustrates the importance of AMAs in the practice of medicine and the need to practise defensive and evidence-based medicine in a developed country like Singapore.   

P.S. The dog will be operated by me today, Jun 14, 2013 after another course of antibiotics and when she eats and is active. The blood tests showed a high total white cell count of 25 and very high number of neutrophils indicating a bacterial infection at the time of consultation with me.

Urine test this time showed struvites crystals. X-rays of the female dog with urethral catherisation and 30 ml of air showed a big urinary stone and no bladder tumour. The owner has been told that kidney stones are also present in the left bladder. Only the bladder stone will be removed in today's surgery.

Every old dog anaesthesia is high risk and this dog is 10 years old and much loved by the family. Pressures are high for any vet as nobody can guarantee no anaesthetic death on the operating table.
tpvets_logo.jpg (2726 bytes)6189. Female dog urethral catherisation and 30 ml of air into bladder provides excellent contrast X-rays


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