A new client is difficult to come by as there are now 47
veterinary practices in Singapore. This was revealed to
me by one veteran drugs salesman who saw me yesterday.
We knew each other for more than 40 years and he had
become busier now, with so many new practices compared
to 4 when I first started out in 1982.
A quiet slim lady brought a black-brown Miniature
Schnauzer to the Surgery as the dog had two loose front
teeth. From her expressions and conversations directed
at me, she would prefer me to handle her case. "I will
do it together with Dr Vanessa as part of my mentoring
process. When did the dog eat?"
"My dog ate at 10 am. Is it OK to do anaesthesia? "
"It is ideal that the dog should not have eaten for 10
hours before anaesthesia as the dog may vomit," I said.
As the owner did not have time to postpone the tooth
extraction, I said, "I will do it at 5 pm which is 6
hours later. It should be OK".
5-year Min Schnauzer, Female Spayed. Chief complaint: 2 loose front tooth with
exposed roots were surprisingly seen. Other teeth in
good condition.
"i used the finger brush and gel," the owner said.
"You must have been brushing too vigorously," I replied.
"The gums of the two incisors are exposed. It is best
not to use the finger brush. In any case, the back teeth
needs scaling."
Chief Complaint - My
Schnauzer has two loose
front teeth
Complaint No. 2 - My
Schnauzer has a big ear lump
that increases in size
2nd complaint:
R ear inflammatory nodule, firm, 7mmx7mmx5mm with
central hole.
"A bee stung her tongue sometime ago," the lady said.
"Any bees seen in the last 2 weeks?" I asked as the
owner said that the lump grows bigger in the past days.
The dog had been scratching the right ear.
"It is best to excise it while the dog is under General
Anaesthesia (GA) for dental scaling," I advised. "If you
don't want histopathology, we will not know whether it
is cancerous or not. A biopsy can be done but it costs
money and delays. The best is for me to excise it since
it is growing bigger day by day ."
The lady agreed to dental scaling and excision of the
lump but not to blood test or histopathology. I asked Dr
Vanessa to check the heart and pulse as well as general
examination of the lungs. All were OK. So, the GA will
be at 5pm to be done jointly.
I wanted to demonstrate how to be efficient and
productive in veterinary surgery to my staff as it is
one thing to lecture to young ones. Show how it is done
will be best.
PLANNING
Scrub & clean ear well before sedation. "Any clipping of
the ear?" Min asked me. "No need," I said.
I checked that Min had prepared the setting up of the
electrosurgery equipment, dental scaling equipment and
covered the operating table with a towel to prevent
electric shocks to the vet on contact. After all this
was done, the dog's dosage of IV anaesthesia was
calculated. "Give 50% of the calculated dose and you
have around 10 minutes of anaesthesia," I said to Dr
Vanessa.
5 min after sedation, electro-excision by Dr Vanessa was
completed within 60 seconds and then dental scaling was
done. As the dog had little tartar due to the teacher's
vigorous finger brushing, the dental scaling of the back
teeth took a very short time.
Productivity means using the correct amount of
anaesthetic drugs and least time to complete surgery and
dental scaling. Therefore, the dog has the best chance
of survival on the operating table. Delays by not
preparing the equipment at first increases the risk and
that would account for some deaths on the operating
table.
The following is
what happened as I asked my intern, Mr Lim to do the
recording. Normally Min would do it but Mr Lim needed to
be hands-on to learn if he wanted to be a vet after his
National Service.
5.22 pm Sedate/IV
anaesthesia at 50% dosage guideline*
5.25 pm Electro-excision
5.26 pm Dental scaling
5.36 pm End of dental scaling
*IV Anaesthesia
Guideline Toa Payoh Vets and Dr Sing Kong Yuen
10kg, healthy,
young dog. Domitor = 0.4 ml, Ketamine = 0.5ml IV
combined
Usually no top up is required in a spay if done
within 20-30 minutes.
This dog - 5 years is not young. The staff is to
calculate on paper the dosage
D= 0.11ml + K=0.14 ml. Total = 0.25ml. Add 0.25ml
Hartmann = 0.5 ml to be given IV.
Normally, the IV anaesthesia lasts around 15
minutes. I noted a very slight reaction to electro-incision
which lasted less than 10 seconds. The dog was
adequately sedated for dental scaling done by Dr Vanessa.
Two teeth and nodule given to owner. I
demonstrated that this case did NOT need any
isoflurane and O2 top up if proper pre-op
preparation had been done and the vet is skilful
in using the electro-surgical instruments.
USE OF ELECTRODES
"Don't bend the circular wire," I said to Dr Vanessa as
she looped the nodule and the wire tilted at 45 degrees.
"It is a very thin wire. It will break and it is very
expensive to buy." The wire loop was originally 90
degrees to the electrode. Training a person how to use
the tools of the trade correctly is important and
acquiring the correct skills makes a vet more
productive. The Vet School provides some knowledge of
electro-surgery but I doubt every of the 60 - 80
students has the chance to handle the electro-surgical
equipment. So they acquire the skills after graduation.
WART OR NODULE?
I would say it is an inflammatory nodule (with a hole in
its centre, possibly bee sting). Dr V thinks it is an
ear wart. "Physically, it does not look like a wart," I
argued. "A wart usually is cauliflower shaped or rough,
not smooth. However, veterinary medicine has exceptions
and I can't say this is not an ear wart. Since the owner
does not want histopathology, we can't send the lump to
the laboratory for examination. Therefore, there is no
definitive diagnosis."
VACCINATION AND HEARTWORM PREVENTION
"I give heartworm tablets monthly," the owner said. "The
last vaccination was 2 years ago." I explained to her
the difference between the usual vaccination and
heartworm.
"You may be getting your priority wrong. In the
countryside like England, where most dogs don't meet
other dogs, some dogs may be safe without further
vaccination as they don't get exposed to many other dogs
as in city living." I explained. "Parvovirus is still
around. Distemper is still present in unvaccinated
puppies. Have you been to England?" I asked. She said
she was in England for two years and understood what I
said.
VETERINARY PRODUCTIVITY & EFFICIENCY
Many employee vets and doctors are not aware of the need
to manage financial costs as this subject is not taught
in vet school in detail if at all. So, they use
materials and waste time in surgery. After all, they
don't pay out of their own pockets and so do not bother
with using excessive packets of sutures or finding more
efficient ways to stitch up a case.
If there is no proper planning, a lot of time and
material are wasted.
This dog would need top up IV anaesthesia or isoflurane
gas to complete the job. As demonstrated by me, the
whole process after sedation took 3 minutes for
electro-excision and 10 minutes for dental scaling.
An example of poor productivity and efficiency in vet
surgery would be as follows:
The dog was sedated for a spay. The legs were then
anchored to the op table. The vet assistant
started clipping the surgical area inside the surgery
room. Then the area would be cleaned. A gas mask would
be given to the dog to deliver isoflurane gas and O2.
The dog struggled as sedation wore off. A lot of time
had been wasted.
My usual method is as follows:
To clip the dog (not ferocious) at the Preparation Room.
Clean the surgical area. Sedate with Domitor and
Ketamine IV. Dog goes into Operation Room. Anchor legs
to table and clean surgical area again. Wait 5
minutes (time spent after sedation would take 5
minutes). Gas mask to deliver isoflurane and O2.
Intubate. Spay. A lot of time is saved and the dog is
exposed to much less anaesthetic in this way.
OUTCOME
The dog in this case was groggy for over 1 hour as I did not use
Antisedan to reverse the Domitor as I deem it not
necessary to wake the dog up so early as she might feel
the pain. Pain-killer and antibiotic injections were
given. The dog went home without problems as at 12 hours at
the time of writing this first draft report. However, in
this final copy, the owner had texted me saying that the
surgical area was weepy and inflamed and what should she
do?
"Hi dr Sing,
I'm .....Brought ....to ur clinic for teeth
extraction n ear surgery on Wed. ....ear is not
doing well...Had inflammation. Can I administer
iodine on her ear? What shd I do? I gv her
medication as indicated, didn't bring her out. Can
y kindly advise? Thanks very much
Younger people
prefer texting. I phoned her and advised daily cleaning
with the iodine and to let the dog wear the e-collar as
she had been scratching the surgical area. She would let
me know if there are problems again.
AN EXAMPLE OF POOR PRODUCTIVITY WASTING MANY HOURS
HAPPENED ON THE SAME DAY
The HDB contractor came to replace the wooden bathroom
door (rotten base) with a plastic one. He dismantled the
door and then found that the plastic one was too narrow
to fit in. 3 weeks ago, another person had come to
measure the dimensions. This was really a waste of time,
being unproductive. This is what I mean by productivity
and efficiency.
"Please put back the old door," I asked the thin
Malaysian man from Malacca with jet black hair. "I have
a lady vet and you can understand that she can't use the
bathroom with no doors. She works to past 8 pm at night.
For men, an open door may be OK"
The contractor actually took the trouble to fix back the
old door and said, "OK. I will get the new door back to
the factory to replace one with correct dimensions
today." He had previously said it might take 2 weeks,
since Chinese New Year falls on Jan 22, 2012 and most
workers had gone home. I was surprised. He even gave me
two discarded wooden boards for me as shelving.
TOA
PAYOH VETS
