On Friday Dec 9, 2011, at 11.40 am, I was in the
consultation room facing Dr Vanessa and Mr Min on the
other side of the consultation table. I conducted a
meeting regarding work performance to ensure that the
quality of veterinary service is up to my standard and
to be free of clientele complaints.
"In many companies, there is a monthly meeting to
discuss work matters like problems and solutions," I
said to both of them. "I don't do it monthly as I expect
both of you to do your part and to adopt my advices for
changes. However, I have to discuss with both of you
work matters today."
One of the topics I spoke about was the need for direct
eye-contact with clients to connect well.
"When a client comes into the consultation room, stand
up and greet him, rather than sit down and look up to
him," I said. "You may be tired but still this is the
proper way to do. You may get a chair and ask the client
to sit down if you wish to sit down to discuss the dog's
health. I always stand up to greet the client throughout
my years of practice or invite them to sit. There was a
complaint of one unfriendly vet who sat down and looked
up at the client...."
I illustrated with my personal anecdotes and gave my
tips as how to handle several cases by Dr Vanessa and
Min who is a vet from Myanmar.
As regards examination of the severely "paralysed"
recumbent panting dog that came in yesterday as a second
opinion, the important things to do would be to collect
blood and urine samples first, before any treatment like
IV drip. If the owner objected to it due to the fact
that Vet 1 had just done the blood test, record this
objection, time and name of the owner. "The dog was
diagnosed as having spinal injuries by Vet 1. How do you
know whether the dog at the time of arrival half dead
and panting and unable to stand up was also suffering
from hypoglycaemia which would be obvious from a simple
blood test?" This morning, I took the dog outside for a
review and he was walking unsteadily as he had been
given IV drip, painkillers and frequent feeding.
I said: "A quadriplegic dog with a cervical fracture or
dislocation would not be able to walk at all. In
addition, there is no rush to do an X-ray which was done
yesterday as the dog's head was twisted and the X-ray
views were not so good," I said. "Go back to basics of
neurology. A quadriplegic dog cannot normally be having
spinal problems in the lumbo-sacral area as the brain
stem and cervical spinal area would be the likely area
of traumatic injury. It is possible that there is injury
in the tail spinal area as evident by the presence of
pain on palpation, but the primary diagnosis should be
the brain stem and cervical area.
"Stabilise the dog, give the IV and medication and take
the neck X-ray later in cases where the dog had a
twisted neck on admission." We all learn by experiences
of handling a case and that include me even though I
have practised for over 40 years. This was an unusual
case. The dog could put weight on the right fore but
limped on the other 3 legs. What was he suffering from?
Was it head concussion, bleeding and traumatic injury as
I suspected? A kick to the side of the head. So, the
right eye pupil constricts on direct light but the left
eye pupil does not constrict and is dilated even this
morning. Yet he can stand up on his own on the right
fore limb and walk a distance like a drunken. I am still
suspecting a brain stem injury and am reviewing this
mysterious case.
P.S. In the evening, the lady and her husband who read
on the internet about IVDD (intervertebral disc disease)
came after work. I was still around as I booked in a
6-week-old male guinea pig for neutering and showed
another Shih Tzu with eye injury in to Dr Vanessa's room
for her to treat.
As for the couple, I placed their Shih Tzu on the table
and shone bright lights onto each eye. The left eye
pupil was dilated despite the bright light. The right
eye pupil was constricted. I said to the couple: "This
showed that the left eye does not have a direct
pupillary response to light." As for
consensual pupillary response, the left eye does
not constrict even when the bright light was shone
onto the right eye.
So, the left eye also did not have consensual pupillary
response. The neurological explanation will sound too
technical to the owners and so I did not want to confuse
them by elaborating.
"Basically, I would say that the traumatic injury is
around the brain stem," I said. "The X-rays showed two
microchips. One was on top of the cervical spinal bone.
Whether this would cause the present problem, I do not
know. The other one was in the armpit area.
However, the dog could put weight on the right fore limb
and this morning, he could walk upright or limped a
distance of over 5 metres before collapsing," I said. I
pinched the toes of all 4 limbs in front of the couple.
Only the left fore limb had no withdrawal to pinching
reflex pain sensation. In veterinary practice,
showing is communication to the owner as nowadays, the
young Singaporeans are so much more sophisticated.
"There is some improvement," I said and the couple could
see it too. "We feed the dog around 4 times a day and
give the necessary vitamins. He can't eat on his own. He
has got the energy and alertness now. But he needs
complete rest and so please do not stay long." The
couple adjusted the water bottle height and reluctantly
left at 7.30 pm.
A HAPPY LADY IN RED CAME TO THE SURGERY
A fair lady in red sheath dress, with black eyeliner
suddenly came into the waiting room and waved at me from
the outside. My consultation room's door has a glass
window on the top half and so I could see who was coming
into the waiting area. This lady, in her prime at around
early 30s, looked quite familiar and since she waved to
me, she must have met me. I had to stop the
meeting which had taken over 30 minutes as I guess my
assistants had enough of my reiterations of things to
do, government and legal processes to be complied with
and records to be written meticulously. Reminders to
staff appear to be part of a manager's job and it is a
role I rather not be involved in. But I was the licensee
and the ultimate responsibility of any clientele
complaint, investigation and litigation is with the
licensee.
I said hi to the lady in red. Fairness and bright red
always demand attention. The lady in red said: "Do
you remember the Corgi? I am coming for the S/D diet."
"I am sorry I can't recognise you," I said. "But I do
remember Oreo. She had seen a few vets and always
passed smelly urine after a course of antibiotics. For
at least 2 years or so. Is she OK now?" I had thought of
following up but had not done so and now one month had
flown by. Just like that.
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"Go Red For Women" campaign to
create awareness of the prevention
of heart diseases in the older
women in Singapore |
"Well," the lady beamed. "She is no longer passing
smelly urine after one month of treatment. Your
medication has been taken and is no more. Her urine is
clearer. Best of all, I don't have any smelly urine in
the apartment after the end of antibiotics as in the
past."
"How many times does Oreo pee and how much does she
drink per day?" I asked. "Did you measure the amount of
water she drinks a day?" It was difficult for her to
answer precisely as she did not take note. She said: "I
can't measure the amount because Oreo drinks only fresh
water and so the bowl of left over water has to be
replaced."
I was surprised that her female spayed dog peed all over
the apartment at such an old age. "An adult dog usually
pees twice a day, in most cases," I said. "The fault
lies with the owner if she pees many times a day," I
said. "The owner has no properly house-training the dog
as a puppy." This frankness was not good bedside
manners.
"Well, I did," she said. "She would hold her urine and
then let go a lot." She spread her arms wide. "Is it
common for dogs to pass a vast amount of urine every
day"
"A dog would pass a lot of urine in the morning for one
time," I said. "But not several times. Your dog has been
withholding the urine until she can't stand it anymore.
You must be beating her up when she had peed all over
the apartment when she was younger," I said. "Holding
urine leads to bladder infection and the smelly urine
that the various vets you consulted before could not
cure. Your dog is not fully cured yet. It is only one
month.
"You need 3 months of S/D diet to know whether she will
be free of urinary tract infection as the S/D diet
acidifies the urine and prevents bacteria forming
struvite sand in the bladder, leading to bad smelly
urine. No other food, dog treats or any other pills."
"My dog loves apples," she said. "Can I give her apples?
She looks at me appealingly for apples when I eat one."
"It is best not to," I said. "You had suffered over 2
years of this problem of smelly urine after antibiotics
after seeing a vet. Now, her urine is not smelly without
antibiotics. Why take risks? Let her urinary tract
system stabilise over 3 months of eating S/D diet and
drinking plain water. Then you may give her apples."
As regards whether the Corgi was harshly disciplined
when she was younger, the lady in red said: "Yes, she
got spanked when she peed everywhere." the lady said.
"This may be why she withholds her urine till the last
moment and urinated a very large puddle of urine onto
the floor. What do you suggest I do now?"
At first I advised confinement and removing the urine
smell in the floor apartments using white vinegar +
water at 1 part to 3 parts water.
As she was moving to a new apartment away from Woodlands
soon, I advised: "Complete confinement for 24 hours in a
room, with a baby gate, for 4-6 weeks. Newspapers with
her urine smell on one side and bed on the other.
Confinement is the key to success. Let the dog out when
you are at home and pick her up when she is about to pee
on the floor and put her into the confined area. Say in
a firm tone 'Pee here.' Give a treat if she does
that or a praise. Persevere. Old dogs can learn new
tricks too especially when you start from a new house."
This case of recurrent UTI seems to be successful but
urine monitoring per month should be done. I gave her a
urine collection bottle and asked her to know volume of
water drank per 24 hours. I hope the new apartment will
be free of dog urine smells as friends can smell it but
owners who live there will not smell it as their noses
are used to it.
Will wait and see. The "living happily ever after" story
has not concluded but it seems that there is a good
clinical outcome of my recommendations and that is what
the lady in red wanted and what all owners whose pets
have long suffering diseases demanded.
PREVIOUS REPORT
 Written
in Oct 31, 2011 (>1 month ago), Recurrent UTI in an old
Corgi is at:
http://www.sinpets.com/dogs/20111044blood-urine-recurs-over10times-old-corgi-female-toapayohvets.htm
The blog has brief
version:
http://2010vets.blogspot.com/2011/10/717-recurrent-uti-in-old-corgi-is-hard.html |
TOA
PAYOH VETS
