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Date:   14 February, 2012  

Focus:
 Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits
Sunday's Interesting Cases
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
14 February, 2012  
toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129
Sunday, Feb 12, 2012

Bright sunny day. Two vets, excluding me are needed on Sunday to reduce the waiting time to less than 15 minutes per client. Some cases like dental scaling takes around 30 minutes and if there is one vet, the clients who come later can complain of waiting over 2 hours.

I had an early meeting with Dr Daniel, Mr Min (assistant) and Mr Lim (intern) in the consultation room to discuss about work attitudes, behaviour, stock inventory, anaesthetic records, case records, surgical processes, efficiency and productivity, wastage of resources and time and consistency to enable my vision of Toa Payoh Vets to be the top 5 practices in Singapore. I asked Mr Lim to take minutes of this first meeting. Clients are younger and much more sophisticated as you can see from the cases described below. It is common for managers to keep reminding the staff of good practices, from what I read in management articles. This takes a lot of time but is necessary. No cronyism or nepotism for me. Those who can't accept my instructions for good practices must find another employer. The practice cannot sustain its growth if staff do what they like, as if their father owns the business.  

Case 1. Stepped upon toe
Golden Retriever's toe fracture as the wife had stepped on him. The dog was standing behind his mistress.  The owners came for a review as advised by Dr Vanessa. But she started work at after 11 am and so I took over the case. The toe was much less swollen. "Still limping but I had removed the bandage as he licks it and it has become wet."

I showed Dr Daniel how I would handle this case as I would have done in a racehorse. Outside the clinic, trotting and walking. He was limping but we knew which leg. Got X-rays. Cost the owners a bit of money.

"How's your daughter's guinea pig?" I enquired as I had clipped its overgrown cheek teeth and it was not eating for the next day. Vet 1 had treated it earlier with some injections but the GP was still not eating and had lost weight. I had the GP under anaesthesia to check the mouth and the cheek teeth were overgrown. So, this was the problem as the GP had become very thin by then.

"The GP is OK now. Eating," the wife said. "My daughter is a medical undergraduate. She ordered the emergency mixture via the internet and it cost a lot of money."

"I did advise her to go to a pet shop that specialises in GP and rabbits and will have it. In any case, how do you know it is expensive?"

Mum said: "I paid $50.00 for the goods delivered on the same day."

corneal ulceration in a 5-year-old rabbit, left eye. why? tooth abscess, other rabbit trauma, others, toapayohvets, singaporeThe internet is now what young adults do. I don't stock the mixture as there are not many cases of GP or rabbits. I had advised her to hand-fed the mashed up pellets and also the medication 6X/day in small amounts and also electrolytes. But she wanted prompt results of return to feeding and ordered the emergency mixture. It ended well for the GP. This case illustrates the importance of checking the cheek teeth and not just the front teeth. A similar case in a rabbit recently had been written in A rabbit has a painful eye and cheek (image, left).

Case 2. Dental scaling from Tampines
I did not expect any early birds as this was Sunday. Suddenly 2 young ladies came in at 10 am with an Italian Greyhound, 4 years, excellent bodily condition, and wanted dental scaling done. "Has the dog eaten?" I asked. "It may vomit out the food during anaesthesia or sedation."

"At 9am," one lady said. "Just a small amount. When I phoned for appointment yesterday, nobody told me not to feed the dog before surgery."
"I will do it at 4 pm, sufficient time to let the food pass through," I said.
"We live in Tampines," the lady said. This would take some time to go back and forth, at least 30 minutes.

To be practical, I got the dog done with Dr Daniel Sing, mentoring him by showing how I would do it. No problem using 50% of calculated domitor and ketamine combination and isoflurane gas. Dog did not vomit. Went home to a happy lady after one hour.

Case 3. Dental scaling for a senior dog
An elderly man came in specifically to see me to get his 8-year-old Jack Russell dental work. No dental done before. Dog was given same as the Italian Greyhound. But older. This is a higher risk. As before, I mentored Dr Daniel Sing. He had his own ideas from his professors and this is to be expected of young graduates. Full of theories and latest knowledge of vet medicine and that is good as you can see from one case of the sheltie with nasal discharge and the excellent X-rays taken.

However, the dog stopped breathing, according to Min. I was out a while but came back within 10 seconds, according to Dr Daniel in review of this case later. No time to test his theories. I know what the professors would have taught about injecting the emergency adrenalin etc. Time is of the essence.

I did cardiac massage, blew air into the lungs by cutting the tightly tied endotracheal tube to both jaws (I don't tie this way but the professors would have taught this is the correct way, in normal situations, correctly). "Give Antisedan injection IV" I said. The dog was revived and was OK. Alert as a guard dog standing up. "Propofol is needed  to continue anaesthesia," Dr Daniel said as there was two teeth left to be scaled and the dog could bite.

"No more IV in this case as the dog's heart may stop," I advised. "Just isoflurane gas by mask and it will take a longer time." The dog was treated.

P.S Propofol seems to be a favourite of recent Murdoch Univ trained vet graduates and is used much in the University. But I don't use Propofol and there is no need for it as there are other alternatives available. New graduates must adapt to the workplace rather than replicating or using what they have seen being used by their professors.

A practice has to manage cost so as to provide the cheapest competitive veterinary services. It cannot stock similar drugs as they do expire and led to a high wastage of resources and money.

AN AFTERNOON CHAT AND ICE-CREAM WITH MY MENTOR
I had lunch with my mentor who is older than me as he wanted to introduce a medical nurse to me for employment. The man was unshaven and that created a poor first impression to me. He could not bother to present a good appearance during the interview and that is a waste of time as I don't employ people who don't take care of their appearances.  Some young people think the world should suit their personal taste - beards and curved moustaches and slippers to work. But I avoid employing such people.  

We discussed about the younger vet graduates who seem to love Propofol - well known as the drug which killed Michael Jackson.

"During surgery, the young vet will inject a bit of Propofol when the dog is about to wake up," he said. "This is a waste of time as the surgery must stop while the dog is being given the injection."

"That is what the University teaches them and probably is doing the same process," I said. "There is no need for Propofol if the dog is intubated and given isoflurane + oxygen gas. In this way, the surgery can be completed fast. I don't trust Propofol as it can be risky if given the wrong dose. In any case, surgery should be completed as soon as possible."

"Yes," he said. "Remember the man who went for liposuction and died. Whenever he moved, the general practitioner gave him more Propofol. He had 13 intestinal puncture wounds during liposuction. So he moved. More Propofol was injected into him."

"Do you use close-circuit anaesthesia?" he asked me. "Yes," I said. "It saves isoflurane."
"The new graduates from Australia Univ prefers to use open circuit and oxygen flow at high rates, more than 4/liter. This is what the University teaches them."

"Their method uses a lot of oxygen and isoflurane," I said. "Some months ago, I discovered that my assistant had to order more oxygen and isoflurane within two months, as if Dr Vanessa was performing over three hundred surgeries and anaesthesia. We don't do such a large number and I knew something was wrong. One reason would be the high oxygen flow rate. Maybe the University professors do not have to pay for the materials used and that may be one reason why they use the open circuit. There may be other reasons such as it is more risky to use closed circuit. I use semi-open circuit sometimes. 

"Semi-open circuit?" my mentor asked. "What is semi-open circuit?"
"There are 3 options in my machine," I said. "Closed, open and semi-closed."
We are owners of the practice and have to account for the bottom-line. The young vets not only take a much longer time to do a surgery but also have their own ideas. But as far as the bottom-line is concerned, they are oblivious to this important factor of private practice.

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