Recovery from propofol only GA

Re: Recovery from propofol only GA

Hannah Wynne Richards — Thu, 23 Aug 2012 13:08:49 GMT

I second that

Wynne

Re: Recovery from propofol only GA

Mark Hedberg — Thu, 23 Aug 2012 12:41:56 GMT

Good to hear; sorry for the dog but I honestly think you were stuck in a difficult situation with no positive side to it. Best wishes for the future!

Re: Recovery from propofol only GA

An On MRCVS — Thu, 23 Aug 2012 12:34:33 GMT

Hello there and I thank you all for your comments!

Very helpful. I have heard nothing from anyone about this case. I will let you know if I get more information.

Re: Recovery from propofol only GA

Rajat — Mon, 20 Aug 2012 11:20:08 GMT

Hi Q

I think you did the best and a very good job at that, dealing with emergent problems and treating what you knew to be pre existing and existing conditions.

The dog may have had the same outcomes elsewhere, or it may have not. It is always tempting to think what if when weaknesses in the link of care are identified. And IMHO, these cases SHOULD elicit some solid soul searching and self questioning, rather than retreat to a fermented grape drink to help soothe our battered spirits. So good on you for putting your case out there, and taking the time to post. You obviously care a lot, good on ya!

Things I would be concerned about would be:

1. Poor history and communication from referring VS/practice

2. Propofol only GA may be considered inadequate in a GDV and I would venture pain medication probably inadequate too

3.Dog going back to day practice for care. This was discussed elsewhere. It 'sounds' and I emphasize because we do not know what the other vets have done or not, but it 'sounds' like you care was more focused and appropriate. It is not necc a criticism as diff ppl do diff things well. If you were providing better ICU care the dog IMHO should stay with you. Especially in its critical state its not in the patients' best interest to travel back to its original practice and prob the only place I would send it is to the referral place.

4. Vet disagreeing with referral- personally I'd treat it as my patient, involve the other vet, but insist on referral as the best option. Technically it is your patient while under your care. Yes it can burn some bridges but its craziness to insist on not referring. Sounds a bit early - being picked up at 630 AM - is there a team to take care of the patient all ready to go at this time?

I completely agree with Hannah. We are not charged with saving owners or pet insurers money. We are charged with taking careof animal's best interests. I think it is less likely to die in a referral setting. But 36 hours post op with the signs you describe makes for a very guarded prognosis anywhere.

I don't think you could have done anything differently though. Did you get BP measurements were they stable and any arrhythmias? Also I dont think you need to worry re low dose ketamine in MLK CRIs they should not cause any increase in seizure like activity. Impressed with your job on the analgesia btw!

Best wishes

Raj

Re: Recovery from propofol only GA

James Laidlaw — Mon, 20 Aug 2012 10:08:32 GMT

We do only have one side of the story remember...

Re: Recovery from propofol only GA

Hannah Wynne Richards — Mon, 20 Aug 2012 09:48:35 GMT

The original veterinary surgeon should have read the Gto PC and agreed to a specialist referral We are not allowed to refuse if the owner requests it Quite frankly the "excuse" that they might have been trying tosave the owner money is totally irrelevant-the cost is not their business The end result might have been the same-or it might not

Wynne

Re: Recovery from propofol only GA

Rob Loxley — Sun, 19 Aug 2012 23:46:10 GMT

[quote user="Michael Woodhouse"]They will have knowledge and info that we are not privy to[/quote]

Maybe if that was the case they should have passed on that knowledge when they passed on the animal?

Re: Recovery from propofol only GA

Luciano Nebiante PGCertSAS — Sun, 19 Aug 2012 23:07:37 GMT

[quote user="Michael Woodhouse"]

Not necessarily so. The dog had a GDV and epilepsy bot conditions potentially quite fatal on their own (GDV especially so). There is nothing to say that the dog wouldn't have gone into DIC and died at a referral centre, in fact I suspect the outcome would be the same.

[/quote]

I do agree about possible outcome, but my impression from the post is that this dog was requiring 24hr close monitoring and critical care, something that the 1st practice apparently was not able to provide.

[quote user="Michael Woodhouse"]

I also think that we should be careful to 'blame' the original vet. They will have knowledge and info that we are not privy to. They may know things unlikely to go well and be trying to stop the owner wasting more money. All referral may have meant is a dead dog, bigger bill and more pissed off owner!

[/quote]

Far from me to blame the original vet, I think there was a breakdown in communication. Also we don't know if the prognosis was discussed with owner.

Glass of wine? Only a good one though!

Re: Recovery from propofol only GA

Rob Loxley — Sun, 19 Aug 2012 22:30:23 GMT

[quote user="Luciano Nebiante"]we all should recognize when a referral is necessary. And looks like there has been a failure in this from the first vet[/quote]

the dog may well have fared no different if referred elsewhere, but given that referral was discussed and agreed with the client then subsequently did not happen, I suspect it will be the centre of any ensuing grief from the owner...

Re: Recovery from propofol only GA

Michael Woodhouse — Sun, 19 Aug 2012 22:30:07 GMT

[quote user="Luciano Nebiante"]This case also reminds us of the limits of a first opinion practice,[/quote]

I think you did a good job. I also think that we should be careful to 'blame' the original vet. They will have knowledge and info that we are not privy to. They may know things unlikely to go well and be trying to stop the owner wasting more money. All referral may have meant is a dead dog, bigger bill and more pissed off owner!

You did your best. All dogs are mortal and going to die anyway. Stop beating yourself up and have a glass of wine.

Re: Recovery from propofol only GA

Luciano Nebiante PGCertSAS — Sun, 19 Aug 2012 19:53:26 GMT

Seems you have done a good job even with limited informations provided by the first vet. This case also reminds us of the limits of a first opinion practice, and we all should recognize when a referral is necessary. And looks like there has been a failure in this from the first vet.

Sad to hear about the dog.

Re: Recovery from propofol only GA

Gerry Henry — Sun, 19 Aug 2012 19:09:33 GMT

Difficult situation but if the owner specifically requested specialist referral then I would have referred and told the 1st opinion VS to butt out or speak to the owner herself. One to learn from but you seem to have done everything you could clinically.

IMHO the first vet needs to accept that if they are going to farm out the care of their patient to a 3rd party, then that 3rd party will make decisions about the ongoing care of the case (be that medication/maybe further surgery/referral etc.) that subsequently becomes necessary.

Agree completely, not always a happy outcome but meddling, fiddling, phone coaching iwill almost always guarantee a cock-up.

Re: Recovery from propofol only GA

Rob Loxley — Sun, 19 Aug 2012 19:08:31 GMT

Sounds like you did your best in a difficult case under difficult circumstances

[quote user="An On MRCVS"]In the morning the ownver very worried about this dog and ask me to refer it to the local large referral centre hospital for the ongoing treatment during the day...

...She says no, she to collect the dog herself and comes in about 15 minutes (at 6.30am in the morning) and brings it to her practice that morning.[/quote]

This seems to be the main issue to consider, and I could well envisage a complaint from the owner given it sounds that their agreement to refer the dog was overruled and the outcome was not good (whether that was as a result or not of the lack of referral). Whether they would complain against the first vet, and/or you for not doing what you agreed, I'm not sure...?
IMHO the first vet needs to accept that if they are going to farm out the care of their patient to a 3rd party, then that 3rd party will make decisions about the ongoing care of the case (be that medication/maybe further surgery/referral etc.) that subsequently becomes necessary.

[quote user="An On MRCVS"] should I have insisted the dog go to referral centre the first day and so on[/quote]

Who is your client - the initial veterinary practice or the dog's owner; their decision at that time (and I assume informed after discussions with you) sounds clear.

Re: Recovery from propofol only GA

Busybee — Sun, 19 Aug 2012 18:54:28 GMT

From what you have described, it sounds like you did a very good job with the dog and the fault lies with the vet at the small GP practice. They have also gone against the owners' (legitimate) request for referral and I would be interested to hear their reasons for not referring. Also why did the referral centre not want to take the dog on day 2?

I'm the worst person for worrying about cases whether they seem to be ok or not, so I know how you feel! I hope other more experienced people than myself on here will comment about what could have been going on with the dog