Seeing practice in India
20 May 2019
BSAVA member, Joe Tristram, of Highcroft Veterinary Referrals at the Longwell Green Veterinary Centre in Bristol, reports on a trip he made to Delhi to see companion animal practice in India.
In December 2018 I spent 2 weeks in a companion animal practice in the Delhi suburb of Gurgaon. It was a very striking experience which proved to be hard work, heart-warming and instructive.
From the outset of the idea there were three aspects which were a cause for concern:
- Is it acceptable to oﬀer advice to colleagues in a developing country?
- Might I find diseases and conditions I would be completely unfamiliar with?
- If I’m going to a developing country in a helpful capacity, wouldn’t it be better to neuter feral dogs or vaccinate them against rabies?
With no clear answers to these questions I arrived in smoggy Delhi on 1 December 2018. I was to stay with the practice owner, and in his household, experienced true, generous hospitality.
Each day started at 6:30 am with my host and me walking the family dog. The local strays knew Sam well, and were friendly with him and therefore with me. We moved on to 45 minutes of yoga-meditation, breakfast, generally cooked by Lalit the practice manager, then oﬀ to work.
In the Huda-market clinic on day one I arrived to find a Labrador and a Spitz, with consultations in full swing. The discussions were in a fluid mix of Hindi and English, and if I was involved they switched to English only. The clients welcomed me as “Dr Joe, the vet from UK”. The conditions being treated were familiar, the level of concern of the clients exactly as it would be at home…this was going to be OK!
Consulting, diagnostic procedures and operating went on until lunch at the practice owner’s parent’s house between 2 and 3 pm. Conversation over excellent food was wide-ranging and often very political. Then a siesta, a walk if time allowed, and oﬀ to the second clinic about half an hour away in a more aﬄuent area of Gurgaon. Evening surgery ended at 8 pm, and often quite a bit later. Our evening meal was in a garden immediately outside the practice, reclaimed from the pavement by my host.
So, what was similar, and what was diﬀerent?
I was struck by the main clinic having a tremendous amount crammed into a small space. There didn’t seem to be a need for a waiting room as clients waited on the pavement outside. The consulting and reception areas were both in one room, about 2.5 x 6 metres, with no door. There was a reception desk, two consulting tables with a space about 60 cm either side for clients and staﬀ, then a set of shelves and cupboards for drugs and equipment. Two consults would be run in parallel in this space, which therefore often meant 10 people and two dogs in a really small space. As for the weighing scales these were embedded in a recess in the pavement outside. Downstairs in a basement was a slightly longer room with kennels, ultrasound, and a glass wall to the operating theatre. Two shop units away was an identical sized space with a pet supplies shop and grooming parlour upstairs, the practice laboratory, X-ray and more kennelling downstairs.
The other clinic we went to for evening surgery (morning surgery was run there by a vet I never met) was much more like a UK practice in terms of the amount of space, and so, by comparison, felt very under-used.
A consultation would typically start with a couple of the support staﬀ heaving a dog on to the table, and the client getting their records out, carefully kept in a practice-provided plastic folder. Many clients had a much greater level of involvement in their pets’ treatment and knowledge of their pets’ medicines than would be typical in the UK. This was necessary, as the practice kept no written records. The practice management system was used for invoicing, and to store laboratory results, X-rays and ultrasound pictures. There would be a quick recap of what had been happening recently, and then very often blood tests, followed immediately by treatment, usually delivered intravenously. All the veterinary staﬀ and many of the support staﬀ were brilliant at finding veins in fore- or hindlimbs in any size of dog.
Butterfly cannulae were used for everything. Many respiratory problems were treated with nebulized antibiotics, delivered there and then on the consulting table. Very few animals were admitted.
Operations would mainly be done during morning surgery, and were generally booked ahead, whereas consults were nearly all non-appointment. The level of surgery was comparable with what many UK first-opinion practices would do, but again client involvement was much closer. People remained with their pets until they were induced, and then often sat immediately outside the theatre while the procedure was carried out, and took their dog home very quickly after recovery. All the drugs used in anaesthesia were familiar, with isoflurane being the maintenance agent. The only dogs I saw hospitalized in 2 weeks were a Shih Tzu after she had had an intestinal mass removed, a street dog with a leg injury, and an ancient black Labrador with diabetes whose owner was too decrepit and too poor (as I understood) to keep him at home. This last case wasn’t really hospitalized, he just lived at the clinic, wandering about inside and outside at will. In a clinic without doors, seeing cats isn’t practical, and I saw only one in the 2 weeks I was seeing practice.
Producing a clinical audit
The clinics were open 7-days a week with, overnight, a dedicated night-vet.
I chatted to staﬀ and clients, and was free to wander about the practice gathering information. I was often asked for my opinion as to what I would do, and became very involved with several cases, seeing them daily. I was invited to scrub in with a couple of operations and to carry out quite a number of ultrasound examinations. Each evening I would write up notes for the day, and at the end of the first week, I took a day oﬀ to write a report, a clinical audit, based on ideas I had garnered from the NHS clinical audit website, with the RCVS practice standards scheme as a background. The practice owner made time in the second week to talk through my audit in some detail, telling me that he found it very useful and would be implementing some of it.
I also spent two mornings in a practice in a poorer district which suggested that the main practice may have been largely typical of current Delhi vets.
The whole experience was tremendously worthwhile, and I was pleased to be invited back, specifically by the second practice to run an audit. I have extended invitations to my hosts to return the visit and work with me in England.