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."
The
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.
TOA
PAYOH VETS
