Thursday, May 19, 2011

448. An ethical and moral dilemma when clients demanded an injection only

I had two cases in the last 2 days of clients instructing me to give an injection and some medication.

Case 1. The woman brought her dog that was not eating and passing smelly vaginal discharge for more than two weeks. I palpated the swollen abdomen and the female Spitz gave up being gentle and started to curl up her lips to warn me not to do it any more. "Just give an injection and some drugs," the woman whose son was my son's classmate instructed me. I suspected closed pyometra which is a life-threatening disease - an infection of the womb.

I still remembered a recent case of the "Vets Who Don't Spay Big Breeds" where the cross bred was euthanased due to poor prognosis. The owners were referred by their vet to a brand-name veterinary practice and could not afford the fees. Much time had been wasted and the dog was no longer standing. Kidneys became infected. As the prognosis was poor, around 40% of survival, the owner decided not to operate and instructed euthanasia. This case quite upset me for this was really a dog that could have been saved if the family vet had tried not to be a one-tracked mind, always referring big breeds to an expensive surgery when his clientele comes from a neighbourhood not in the upper-middle class of Singapore.

Now, this woman demanded an injection. I did not do it as I advised X-rays and blood tests first to aid in the diagnosis of pyometra. She phoned her husband first she said. The husband and I exchanged words over the phone. He then asked his wife to go to another vet.

Case 2. In this case, the 14-year old Shih Tzu had passed a lot of blood in the urine and had difficulty peeing. "This is usually urethral obstruction, with stones blocking the urine flow," I said. But the owner insisted on an injection and medicine and wait-and-see. Now, give what the customer wants? If not, the customer goes to the competitor.

This is the type of ethical or moral dilemma. One could milk the client by doing what she wants. Revenue generated. The dog would have to come back again as the drugs will not work. This is obvious to the vet but the client wants to save money. I know the medicine will not work and refused to obey her wishes. The woman wanted it to save on costs. So there was an impasse.

She left the Surgery to consult somebody, probably her family or husband carrying the dog with her. I had asked Dr Vanessa to handle this case, under my lead management. This was going to be a hot potato if not handled professionally. I mean, if the vet gives the injection and medication as requested, the dog will not recover. The other family members start to curse the vet for incompetence especially if the dog were to die from renal failure and infection when sent to the competitor and treated belatedly. The competitor would cover for himself or herself by saying that I should have had done the blood test and the X-ray and give proper treatment early and the dog would have been alive. Not just give an injection and some antibiotics. What an incompetent vet!

Well, to make a long story short, the owner agreed to the X-ray which I told her was not necessary if she wanted to save costs on veterinary surgery. She did not believe my diagosis of urethral obstruction and so she agreed to the X-ray. A surgery by opening the bladder and getting out the urinary stones and pushing back the stones in the penile urethra into the bladder would save some money for the cash-strapped owner.

"Suck out all urine," I said to Dr Vanessa. "Pump air into the bladder and the stones would be seen clearly." She said: "The cathether cannot be passed into the bladder, so there is a urethra obstruction." Later she told me that another catheter could pass into the bladder and she got around 10 ml of bloodied urine which would be sent for urine analysis.

The X-ray came back with around 5 stones below the os penis and more stones in the urinary bladder. "How you manage this case is up to you," I passed the case to Dr Vanessa as we work well together.

My diagnosis was correct without the need for the X-ray but X-rays would be better as it is part of evidence-based medicine. Now, what to do next in view of the old age of the dog (14 years old) and the financial situation of the owner.

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