21. Defensive Medicine Costs More

From: ...@starhub.net.sg>
Subject: Bill for treating wound and removal of maggots
To:
Date: Monday, December 28, 2009, 12:08 PM

As spoken, I enclose a copy of the bill itemizing the treatment of my Husky. In your professional opinion, is the bill justified? I know there is nothing I can but at least I want to know that I have been overcharged or not?
 
Thanks.
 
Regards
Name of owner
E-MAIL REPLY FROM DR SING

1.  It was nice talking to you yesterday. Thank you for your e-mail of your vet's bill. As I have not seen the extent of the wound and was not present, I cannot say definitely whether you have had been overcharged when you said you were billed over $600 for treatment of a maggot wound in your large breed dog. The total bill was $641.20.

2. My comments are that I don't usually conduct the following for the treatment of maggot wounds performed by your vet, viz.,

2.1  Heartworm test  $50 (not relevant to maggot wound treatment).
2.2  General Health profile $150 (some vets perform this test to screen the dog's health prior to sedation). 
2.3  (Insecticide) Interceptor Spectrum $65
2.4  Buster Collar 25 cm $23
2.5  (Insecticide) Negasunt powder  $18
2.6  (Pain-killer) Rimadyl Inj $30
2.7 (Pain-killer) Carprofen 50 mg $9

Therefore, the costs would be reduced $345 and your final bill might be $641 - $345 = $296 assuming I used the same procedures as your vet. No 2 cases are exactly alike, just as no two condos for rent are exactly alike. I am using condo rentals are an illustration since you are familiar with this industry.
 
3. However, I do hospitalise the dog for 2 days for observation if the maggot wound is deep and large. I don't know how deep is your dog's maggot wound. In addition my consultation fee is $10 more than your vet. If you shop around there is at least newer vet practice charging consultation fee at $18 which I believe to be the lowest in Singapore. 

3.1 If you deduct $296 for the above case, my fees may be considered cheap at $200-$300 range, since I don't use items in paragraph 2. But some owner may have the perception that I am not a good vet since I don't give the extra drugs what all good vets should give and I had not practised defensive medicine by doing general health blood test and heartworm test.  

4. I use the real estate rental of a condo as an example since you are familiar with this topic. An owner in the same condo may rent out his apartment for $5,500 per month and you would get a rental of $6,500 per month.

4.1 Will you be considered a greedy landlord since you are overcharging by $1,000 compared to your neighbour?  You may claim that your quality of renovation, furnishing and furniture is vastly superior in quality and this may be true. Prospective tenants usually view various condos. This would probably be the case, as I know that is a common practice. No tenant will rent the first condo they see in Singapore. Supply is greater than demand. On the other hand, your tenant at $6,500 rental for your condo has the company budget fixed at $6,500 and may have other disbursements from you. So, your $6,500 rental may be justified. Still it appears you are overcharging if the market rental is $5,500. If there is such a thing as market rental. There is no fixed charges for veterinary treatment by the way.

5. Some dog owners do phone up vet practices to get quotations and then go to the cheapest vet in town. When the fees need to be kept low, obviously, the dog does not get general health blood test, painkillers and Buster collars. Some owners have built a client-veterinary relationship of trust and goodwill and the vet will act according to the owner's financial means in the best interest of the pet and the client.  

6. Back to the condo rental industry, if the tenant wants a low rental, he has to sacrifice for the poorer quality of furnishing. If the pet owner wants the least veterinary cost, he has to scout around and find the least cost veterinary practice and there are such practices if you do your research. 

7. I am sure that this dog with maggot wound will heal beautifully and that your daughter will be most happy. Call for quotations from vets all over Singapore next time.

8. In conclusion, I would say you are overcharged by $50 since vets in general don't consider the heartworm canis test necessary in the treatment of a maggot wound.

8.1 On the other hand, your vet may need to know that your senior dog did not have heartworms as he could have died when given sedation and the Interceptor Spectrum. Your vet could be sued for "medical negligence" for not checking whether your senior dog had heartworms and pre-sedation blood test first before sedation was given.

Defensive medicine is a good defence against litigation and veterinary complaint investigation. This apparently had been practised by your vet and you were charged for the higher costs.   

8.2 Your dog was given the best things in veterinary medicine and it burnt a small hole in your pocket. You said that the practice was not a famous one equivalent to the human "Mount Elizabeth Hospital", but had you gone to Mount Elizabeth-equivalent, your bill would be more than $600.

8.3 It is really hard to compare as there is a vet practice that will treat a maggot wound for around $100 - $150.      

9.  Shop around if you want the cheapest service provider. Inform the vet that you are in dire straits so as to get the least cost treatment. No frills. A house brand rather than branded goods. Ask for steep discounts and drive a hard bargain before the treatment. Risk being blacklisted or shown the door for a few dollars less.

9.1 I relate a personal incident I suffered recently. One day, a door-to-door vendor came to my surgery to sell goods. I bought a "Made in China" belt from him for $10.00 to give him some business since I know he needed some income as door-to-door sales are extremely hard work with more rejections than sales.



The next day, the buckle fell off and threads start peeling off the belt. I had to throw away the belt. So, was I being cheapskate? I should have bought a Pierre Cardin belt at $58.00 and would not have to show my clients that I wore a belt without buckles. It looked as if I was down and out. In dire straits. But my clients did not say a word and I shopped around for a "branded" belt 2 days later. Prices of goods and services vary greatly and if one goes for the cheapest, one should not be surprised at getting shoddy goods or services.

10. I hope my reply is entertaining and to your satisfaction and put a smile on your face. I wish you a Happy and Prosperous Chinese New Year.

20. Against Medical Advice

Profuse salivation after de-ticking by the groomer yesterday. The owner sent the dog to the emergency vet. Dog was given charcoal tablets and sent home. The owner was told to return in 2 to 3 days' time for a blood test.

Yet the dog started to salivate again in the morning. I was consulted. No more ticks. The owner was worried about the salivation and some shivering.

"Did you apply a 'Spot-On' insecticide onto the spinal area earlier?" I asked.
"Yes," the owner said. But ticks were still present and so she went to the groomer to get de-ticking done.
"The groomer must have applied a tick wash," I said. "Did the dog lick his paws and body?"
"Yes," the lady replied. The dog looked all right. There was some wet whiskers seen, due to salivation.

The dog was bathed thoroughly before its coat was clipped short. An IV Hartmann's solution was given. It was bathed again after clipping. Around 1,000 ml of IV drip was given to dilute the poison if possible. The owner wanted the dog home on the same day despite my advice to wait for one day for observation.

So the dog went back at 9 pm. This was one of those cases that should be warded for one or two days for observation, but the owner decided against medical advice and must be respected.

Day After My Treatment
The owner phoned me to say that the dog was not behaving normally. However he was eating and had no vomiting, salivation, shivering or diarrhoea. "It will take around 7-14 days to recover if the insecticide poisoning has not affected the brain, liver and kidneys," I advised.

The groomer phoned me and so I was able to know what had been used. The owner had phoned him earlier and so he phoned me to find out about the dog. He had used 1 cap of the Carrington Dog Wash Concentrate in around 800 ml of water. "No complaints from most owners," he told me. "Except for a few cases of salivation."

"This dog could have licked the insecticide from the matted hairs in its paws," I said. "The owner did not accept my advice to de-matt the paw hairs," the groomer said. So, the insecticide could have accumulated inside the paw's matted hair and the dog could have licked it and started salivating. However salivation is a sign of insecticide poisoning.

This is a case likely to result in negligence complaints and litigation if the dog has died. The vet and groomer have to be very careful nowadays. So far, so good.

P.S.
Carrington Dog Wash Concentrate contains pyrethroid insecticide and is sold in some Singapore pet shops. Not all dogs need to be warded for suspected insecticide poisoning but some dogs such as this case would be advised as the IV drip needs to be given over 24 hours. If owners go against medical advice, give the owner a release form stating that the owner wanted the dog to be discharged immediately and by 9 pm in any case. I did not give the release form in this case and sometimes this omission would haunt me if there was litigation.

Spot-on insecticides are said to be ineffective for some dogs but effective in others. A spot-on insecticide and a tick wash sometimes cause profuse salivation in dogs, depending on dosage. Owners who acted against medical advice should be given a release form to sign to protect the veterinary practice against litigation.

12. Paraphimosis in a 5-year-old Cavalier King Charles. What to do?

DRAFT
Updates at: www.toapayohvets.com. Goto DOGS - Surgery webpage - balanoposthitis.


Paraphimosis - protrusion of the penis with an inability to retract the penis into the prepuce.

Causes:
1. Idiopathic - No known causes
2. Small preputial orifice
3. Weakened preputial muscles
4. Trauma
5. Shorter prepuce

Possible medical conditions
1. Posthitis - Inflammation of the prepuce.
2. Phalitis - Inflammation of the penis.
3. Balanitis - Inflammation of the head of the penis (glans penis).
4. Balanoposthitis - Inflammation of the head of the penis and the internal layer of the prepuce.

Treatment:
1. Surgery to prevent balanoposthitis?
2. Retract prepuce to the level of the bulbus glandis and wash it with soap and water every day.
3. Others?










Dec 16, 2009.
The case is being reviewed for the next 2 weeks as the dog is given medication.

The small preputial orifice got swollen 6 weeks after the first treatment. This could be due to the dog's lifestyle - humping on cushion though he is neutered at 2 years of age (belated) and sunbathing for 15-20 minutes a day nowadays.

When the inflammation is gone, surgery may be the only option as daily pulling back of the internal layer of the prepuce to wash away the smega and pus may be too much work for the young working lady owner.