Singaporeans hate long waiting times at clinics to see a
doctor and so I have started procedures to ensure that
the waiting times should be less than 15 minutes. Many
vets don't realise that clients hate to wait too long on
Sundays.
For example, a neuter case on a Sunday can take up
longer than 30 minutes (from sedation to last stitch) if
the younger vet has no sense of time management. Or it
could be done in 15 minutes with planning and pre-op
preparation. Now I monitor the younger vets' efficiency
in veterinary surgery by using time of sedation to last
stitch and review the outcome of their surgeries (repeat
stitching, stitch breakdown, infections etc).
Vets who don't make the mark will be asked to go. There
is no other way because a higher standard of care must
be achieved if Toa Payoh Vets is to be ranked by clients
as the top 5 in Singapore. There are SOPs (Standard
Operating Procedures) to be adopted and stuck to and I
don't tolerate any lapse. AMA (Against Medical Advices)
have to be recorded and medical records are to be
written in greater detail than in the past.
A pug came in for neuter. I assigned the surgery to Dr
Daniel and monitored the time he took. I ensured pre-op
planning and preparation. Domitor and Ketamine at 50%
and isoflurane gas. The sedation time to last stitch was
around 30 minutes. It was OK but I said it could be
shorter.
A dwarf hamster came in for left eye discharge and
reddened left ear. Dr Vanessa was assigned the case. Not
just some ear drops as the owner had been given such ear
drops by the pet shop or Vet 1. Dr Vanessa scoped the
ear. "A general anaesthesia had to be done to irrigate
the ear," I said. The owner gave his consent. I asked Dr
Vanessa to do a proper time management as she had other
cases. In the end, I did the hamster myself with Dr
Daniel as she other cases to attend to on this busy
Sunday afternoon when clients came all together around
1-3 pm. I will have to follow up on this hamster.
A Schnauzer came in for a routine vaccination. Dr Daniel
did it and told me that the dog had a black lump on the
right of the backside and he had advised the owner to
get it excised. It was good that he did a general
examination and detected this lump. Some vets would just
advise "wait till it grows bigger" but many tumours, if
cancerous, grow bigger without the owner being aware of
it, till it is too big.
The owner declined and wanted to wait and see. "The
black lump is a melanoma," I said to the middle-aged
couple with a teenaged daughter. "It has grown big but
not that big yet. It is very black. Our advice to you is
to remove it while it is easy to do so. And less
expensive. You need not accept the advice. However, you
cannot not say that the vets did not advise you during
vaccination. When it grows bigger or spread to other
parts of the body, you cannot blame the vets for not
giving proper advice. Big tumours need big cuts and
longer stitching. You have to pay much more. Older dogs
like older people get tumours and it is better to get
them cut away when they are small. Saves money and less
worries of the tumours being cancerous and spreading
later."
The couple was vacillating for some reasons. After all,
they came to vaccinate their 5-year-old female
Schnauzer. They were worried about the dog biting the
wound and the lack of care-givers and wanted to wait
later.
The vet's duty is to advise properly. "How much it will
cost?" the father asked me. "$150 as it is a small
tumour as anaesthesia will not be long and therefore the
charges are less," I said. "Can surgery be done today?"
he asked. "Yes," I said.
SURGERY
"This is a simple surgery," I said to Dr Daniel." It
takes 5 minutes (from sedation to last stitch) to do the
whole process." Dr Daniel looked at me incredulously. I
was sure that he would adopt what the professors had
taught him but that would be the traditional way.
Sedate, intubate, use scalpel to make an elliptical
incision with a wide margin. Undermine with scissors.
Stitch up the two ends. How could the whole procedure
take 5 minutes? I must be getting senile?
The dog was given Domitor and Ketamine at 50% IV.
Isoflurane gas by mask was given though I would say it
was unnecessary as you would see what I mean. From my
experience, this dosage would be sufficient for a snip
and a stitch.
"Pull up the
elongated melanoma (1.5 cm x 0.5 cm, with a stalk) with
forceps," I said to Dr Daniel. Snip it off with scissors
around 3 mm away." Dr Daniel took a pair of curved
scissors and snipped off the melanoma as advised.
The melanoma came off with about 50% of the dermis
intact. There was the grey dermis but no subcutaneous
tissues seen. "No need to stitch," I said as small
bleeders ooze blood. "Just potassium permanganate powder
to stop the bleeding. Cover the wound with plaster."
Dr Daniel had not seen such wounds being covered with
plaster. This was the bulging backside area. Wouldn't
the plaster just drop off, he must have wondered but did
not speak his mind. I got two sticky plasters and
covered the wound. The type you used when you cut your
finger. They did not drop off.
This was one of those easiest surgeries in the world.
Snip and stitch. But no need to stitch as the melanoma
had a stalk and the skin was clear of melanomas by 3 mm.
The owner did not want histopathology as they were also
cost-conscious. So, none was done.
Veterinary surgeries present many variations. It is up
to the vet to know what to do and how to do it
efficiently. The surgery text book offers the standard
method but there are better ways not described in the
text book, as in this case.
Tips for Dog Owners
The best time to spay your dog is 2 months after the end
of heat
TOA
PAYOH VETS
