Undiagnosed diabetic dog

RE: Undiagnosed diabetic dog

Anthony Todd — Sat, 05 Sep 2015 13:52:43 GMT

[quote user="Robin Grimmer"]You've still only got the client's version of events.[/quote]

True. and if the vet was in my "good" category he/she would say "**it, you may be right, didn't think of that etc. etc." and I would do my best to ease the change of direction so everyone was happy.

But, how many of us have done a full exam: no real clues, all negatives or normal, and as the client leaves, having been questioned forensically, they say "Why is he drinking so much water then?" or "Can you just give him something to stop his terrible cough?".....

RE: Undiagnosed diabetic dog

Robin Grimmer — Sat, 05 Sep 2015 13:39:48 GMT

You've still only got the client's version of events. Admittedly the notes don't really back the other vet up. Call them and ask them why they didn't give insulin - because that is what it all boils down to. You may get a completely different view, ie client didn't want to treat, took home to consider pts. Hence them giving them the notes in case it crashed ooh.

RE: Undiagnosed diabetic dog

Anthony Todd — Sat, 05 Sep 2015 11:33:14 GMT

[quote user="Dagmar Steele"]I would always speak to the vet on duty personally.[/quote]

I hope attitudes have changed since I was practising.

[note the correct "s", pedants and others]

Back in the day attempts to correct misdiagnoses, change treatments or correct errors by direct contact with most other vets were badly received, often with derogatory personal comments, threats of supersession or deflections to "owner-itis" and always disputed, unless they were vets I knew personally.

The reception I received was always proportional to the opinion I held of the ability of the vet concerned and inversely proportional to the vet's opinion of him or her self.

I gave up, thought about the patient, told the owner my treatment given and diagnosis and let the owner carry the news back if they so wished. [ I know, I know but see below]

Of course, if there were details vital to the case then I phoned, but see above; potential diabetics would be an obvious one.

Most of them were long term skins or gastrointestinal problems and the smart owners didn't mention previous treatments or opinions anyway.

if I refused to treat without the history it was obvious the animal wouldn't be relieved and would be presented to the next vet definitely without any history! All the owners ever want is to get their animal better!

Helped a few animals and prevented any attacks of apoplexy, insult or abuse.

RE: Undiagnosed diabetic dog

Dagmar Steele — Sat, 05 Sep 2015 10:47:06 GMT

[quote user="An On MRCVS"]

As an employee of an OOH clinic, I would not feel comfortable speaking to the member practice - it's not really my job is it? My bosses are unlikely to want to get involved as they could lose a member practice if they start commenting on their work. And do I really want to get the RCVS involved? - I've had the occasional complaint to deal with as a lot of us have, and it's not a pleasant experience. The vet who originally saw this dog most likely needs to be working in a supportive environment with experienced vets to learn, rather than having the RCVS getting involved??

[/quote]

Please take what I write next with the knowledge that I'm not English but German, hence diplomacy might not my strongest side. I would always speak to the vet on duty personally. I would not involve any bosses or any officials in the first place. I'd just let them know the patient has died and ask them why they had decided on their treatment plan because I was wondering about it, either I could learn something from their thoughts or they might from the outcome. I tend to put myself in other peoples shoes. If I had been in this vets shoes I would be more than grateful for a heads up and a chat about it. I own a first opinion practice and although our system is a bit different from yours I have a referral centre I send most of my emergencies/critical cases to. As I am not free from fault I have had the occasional chat with their specialists about cases which could have been dealt with better with hindsight. Last case involved an epileptic GR I tried to switch to Pexion and weaned off Phenobarb that went into cluster seizures. I've learned a lot from the chat with their (lovely) neurologist. I will definitely keep sending them patients, they do a good job and if I make mistakes I like to learn from them rather than burying them under the carpet. What I would do if the response would be different from what I hope it to be I'm not sure, I don't think I would report someone on the first incident, but if deadly mistakes occur on a regular basis I'd probably think twice.

RE: Undiagnosed diabetic dog

Hannah Wynne Richards — Sat, 05 Sep 2015 09:04:44 GMT

I'm going riding this afternoon - along some forestry tracks that are very popular with riders. If I hear hoofbeats approaching, then I'll take it for granted it will be a zebra.

Wynne

RE: Undiagnosed diabetic dog

Jo Dyer — Sat, 05 Sep 2015 08:57:25 GMT

Thanks Anon for giving us more information. It appears, with the benefit of hindsight and further information, that an important part of the diagnosis has been missed by the day vets' practice. In the OP you ask what you should do. You should do exactly what you always do after an OOH shift, and send the notes on the case to the day vets. Hopefully that will trigger a clinical governance meeting/serious event review, during which all the facts can be assessed in a no-blame way and lessons learned for the future. Quite a few forward-thinking practices are doing these now and I would love to see a world in which self-reporting of mistakes and near-misses was the norm because there was confidence that blame would not be apportioned but the meetings would be used to improve patient care and welfare.

We have no idea why the diagnostic information gained did not lead them to the conclusion we would expect, but there will be a reason, and it is up to them to find it. One mistake does not an incompetent vet or practice make.

[quote user="An On MRCVS"]As far as I am aware the NHS is developing a more open approach to colleagues reporting poor performance anonymously. But what mechanisms are in place for vets, and is it something we need to think about?[/quote]

The NHS are trying to bring in the 'safety culture' I mentioned above but I think we have a lot more chance of developing it properly than they do, because of being a small and utterly patient-focussed profession. They have also been trying to encourage whistle-blowers to go to management about systemic bad practice such as that seen at Stafford Hospital. Several thousand people died of neglect and starvation there before anyone said anything though, so that change may take a while too.

[quote user="An On MRCVS"]All the practices I have worked in over the years have been very supportive. [/quote]

I am really glad to hear that, so let's extend it to colleagues outside our own immediate practice. As an OOH centre they are pretty much your direct colleagues anyway, as you are all working together for the same clients. I suppose if the feeder practice regularly provided far more questionable cases than any other, your practice could suggest a joint clinical governance meeting and ultimately if you weren't comfortable with their modus operandi you'd have to divorce them. But I'd say that would be a very long way down the track.

By the way, is it just me, or is every sick 8 year old cocker an autoimmune diagnosis unless proved otherwise?

RE: Undiagnosed diabetic dog

Evelyn Barbour-Hill — Fri, 04 Sep 2015 23:13:21 GMT

Thank you for coming back, An On, and giving us a bit more explanation. Thank you also for your admission that your hearsay evidence of other failings is not really relevant.

[quote user="An On MRCVS"]I have no intention of making this a crusade and I have never in 16 years reported a colleague. I just think that if a vet apparently misses a fairly obvious diagnosis and the animal dies as a consequence (yes, it may have died anyway) then maybe it should not be ignored?[/quote]

[quote user="An On MRCVS"]As an employee of an OOH clinic, I would not feel comfortable speaking to the member practice - it's not really my job is it? [/quote]

[quote user="An On MRCVS"] And do I really want to get the RCVS involved? - I've had the occasional complaint to deal with as a lot of us have, and it's not a pleasant experience.[/quote]

Well, you have to decide for yourself whether you wish to be a self-appointed "whistleblower" on some rather scanty evidence that is open to various interpretations.. If you do, then do it.. If not, drop it.

Sorry if that sounds rather harsh. Maybe you just wanted to get it off your chest.

RE: Undiagnosed diabetic dog

An On MRCVS — Fri, 04 Sep 2015 22:37:18 GMT

Thank-you for the replies and variety of opinions.

Although I regularly look at the forums, this is the first time I have posted.

Since there has been some interest in the post, and I did not want to make the original post too long, just a few points to clarify.

The clinical notes, as given to me by the client, were from Jupiter/Enterprise. I am not aware that when printing clinical notes from Jupiter that you can 'edit' them i.e. delete bits.

I am not going to write down all the clinical notes, but the bits that worried me (and led me to suspect that DM/DKA had been missed) included :

the comment on the interpretation of the original bloods (which had BG of 54) - 'bloods are back and indicate a multiple organ issue. NB high glucose - could be pancreatic compromise not diabetes'
the next day - ' glu very high again will not read on the glucometer, adv try and get a u/s'
the treatment given was IV fluids, cerenia and noroclav. So obviously some treatment plan had been formulated.

I agree that we have to be very careful about interpreting client communications/behaviour. In this instance, the client was a human nurse. She commented that she had wondered if the dog was diabetic and why insulin had not been given to the dog. She said that the dog had been sent home that day and warned it may die overnight, if not then she was to return the next day for X-rays. She seemed relieved to have been given a diagnosis, albeit a bad one, and was willing to spend money on the dog for us to stabilise.

The other bad practices which I raised in the original post were viewed directly by a trusted colleague of mine, although I don't know if it was the same vet on duty at the member practice. I probably should not have put them in the OP as it is not directly related to this case.

I agree that my job is to see the clients of our member practices and not to comment directly to the clients about any aspects of the case that I think have been mis-managed. I am very careful what I say in consultations if it is evident that this is the case (which happens rarely, but does happen).

I have no intention of making this a crusade and I have never in 16 years reported a colleague. I just think that if a vet apparently misses a fairly obvious diagnosis and the animal dies as a consequence (yes, it may have died anyway) then maybe it should not be ignored?

As far as I am aware the NHS is developing a more open approach to colleagues reporting poor performance anonymously. But what mechanisms are in place for vets, and is it something we need to think about?

I've not really experienced the 'competitive and judgemental culture' that Jo talks about. All the practices I have worked in over the years have been very supportive.

RE: Undiagnosed diabetic dog

Clive Ansell — Fri, 04 Sep 2015 22:26:47 GMT

[quote user="Virginia Campbell"]I think this is probably the case. Suppose they admitted the dog while the owners went home to dither over whether they wanted to commit to treating a diabetic blind dog. Suppose the practice had an open bottle of neutral insulin that they used but didn't charge for as it was already opened, and didn't record it on the clinical record. Suppose it was really busy, or they were just a bit slack, and didn't record all the discussions and exactly what the dog had (if it's a small practice, there may be less need to write everything down at the time as the treating vet knows the case and thinks, ah well they'll treat it or euth it, either way the ball will be rolling quickly so I'm not going to forget the detail in a couple of days). Suppose the owner bailed out before the vet had a chance to get the bg under control and did this [/quote]

But surely the practice would make sure the clinical notes were up to date and complete before printing off a copy for the client, would they not?? I'm sure I would.

Doesn't it seem odd that this client had a copy of the notes and blood results with them? how many on here hand out full sets of notes just in case the client needs to go to an OOH clinic ? If I am transferring a case, or think the client may need to go OOH I will forward a history directly to the clinic. I have never had a client request notes, and working in OOH clinics have never had a client show up with them.

RE: Undiagnosed diabetic dog

Evelyn Barbour-Hill — Fri, 04 Sep 2015 22:24:31 GMT

[quote user="Virginia Campbell"]I agree the best and quickest way to the other side of the story is to ring the feeder practice, under the guise of "oh I saw that dog, I'm sure you were wondering where it had got to, tut tut, owners hey?" and give them a chance to explain. [/quote]

Well that should not be necessary, because the OOH service is supposed to report back to their client practice without delay anyway, isn't it?

Unless you feel like playing Detectives, of course.

RE: Undiagnosed diabetic dog

Nhombokisheni — Fri, 04 Sep 2015 22:20:19 GMT

[quote user="Jo Dyer"]

I am a bit horrified by the tone of the OP. I have never met (in person, not 'heard of via hearsay';) another vet who was not caring, conscientious and adequately competent. Maybe I'm just lucky. However, my default would always be to assume that about my colleagues.

To take one clinical case, listen to one side of the story, and consider reporting a colleague to the regulator seems to me to be symptomatic of a deeply unpleasant competitive and judgmental culture which does unfortunately seem to exist in our profession, and which I think can make less-than-totally-confident vets feel even more anxious and vulnerable.

This is not a personal attack on you, anon, far from it. As I say, I think it is symptomatic of a culture which should not be tolerated, and we should all get our heads around being more supportive of each other as the default.

[/quote]

Firstly I believe the OP was clear that the concern is not just limited to one case. Secondly, I don't know if it's just me, but painting every vet with the same brush is rather harsh don't you think. Just because some vets are "competitive and judgemental" hardly makes this trait a culture....if it is then I must be unique and so must be a lot of forum members here.

Genuine incompetence exists........so does genuine oversight and "cutting of corners"....and tongue twisting clients who will do anything to avoid blame. Unfortunately the real victim is the patient.....and it is only just that someone speaks for the poor animals. Genuine, factual reports have nothing to do with this culture thing you mention. Are you intimating that if you come across such worrying observations you will turn a blind eye for fear of being labelled "judgemental"???? I sincerely hope not.

As for having not yet seen incompetence in the profession, it's either you have indeed been very lucky to meet only competent vets OR you have simply, subconsciously elected to not see it..........

RE: Undiagnosed diabetic dog

Virginia Campbell — Fri, 04 Sep 2015 21:25:48 GMT

[quote user="Clare Tapsfield-Wright"]the vet would not have run glucose tests had they not suspected DM and may not have written their diagnosis in the clinical notes that you have seen . [/quote]

I think this is probably the case. Suppose they admitted the dog while the owners went home to dither over whether they wanted to commit to treating a diabetic blind dog. Suppose the practice had an open bottle of neutral insulin that they used but didn't charge for as it was already opened, and didn't record it on the clinical record. Suppose it was really busy, or they were just a bit slack, and didn't record all the discussions and exactly what the dog had (if it's a small practice, there may be less need to write everything down at the time as the treating vet knows the case and thinks, ah well they'll treat it or euth it, either way the ball will be rolling quickly so I'm not going to forget the detail in a couple of days). Suppose the owner bailed out before the vet had a chance to get the bg under control and did this[quote user="Clare Tapsfield-Wright"]he dog may have been taken home having been diagnosed to say goodbye prior to PTS and then not represented as agreed , only coming in when the dog collapsed.[/quote]

I agree the best and quickest way to the other side of the story is to ring the feeder practice, under the guise of "oh I saw that dog, I'm sure you were wondering where it had got to, tut tut, owners hey?" and give them a chance to explain.

RE: Undiagnosed diabetic dog

Clare Tapsfield-Wright — Fri, 04 Sep 2015 18:49:10 GMT

on reflection I have stapled a wound in a conscious patient , very small clean wound , very elderly amenable patient and I am sure genuine errors occur from time to time where bloods are charged for and not run so there would need to be a lot more bringing of profession into disrepute . Ring the vet up and have a chat

RE: Undiagnosed diabetic dog

Evelyn Barbour-Hill — Fri, 04 Sep 2015 18:33:57 GMT

[quote user="Martin Atkinson"][quote user="Evelyn Barbour-Hill"]If I were a client practice of this OOH service ( this is purely hypothetical of course) and I found out you had "reported" this chap to RCVS, I'd cease to be a client of yours pronto.[/quote]If you were so bad that you needed reporting and it was not just an isolated case you may not be in need of an OOH clinic as you wouldn't be practicing! [/quote]

That should be "practising".

Read posts more carefully.

I'd leave the OOH service immediately if I found out they had "reported" (oooh, I'll report you!) some other practice.

Especially if they had done it on the basis of one case of which they were not in possession of all the facts, together with a lot of "we are aware of" hearsay.

RE: Undiagnosed diabetic dog

Martin Atkinson — Fri, 04 Sep 2015 17:55:46 GMT

[quote user="Evelyn Barbour-Hill"]You're the OOH service, this practice is paying you to see their clients OOH, not to pick over and criticise their work.[/quote]In general Evelyn I would agree but sometimes there comes a point when it has come to your attention that someone is so incompetent that you cannot ignore it,

[quote user="Evelyn Barbour-Hill"]If I were a client practice of this OOH service ( this is purely hypothetical of course) and I found out you had "reported" this chap to RCVS, I'd cease to be a client of yours pronto.[/quote]If you were so bad that you needed reporting and it was not just an isolated case you may not be in need of an OOH clinic as you wouldn't be practicing!

RE: Undiagnosed diabetic dog

Evelyn Barbour-Hill — Fri, 04 Sep 2015 17:47:39 GMT

You're the OOH service, this practice is paying you to see their clients OOH, not to pick over and criticise their work.

If I were a client practice of this OOH service ( this is purely hypothetical of course) and I found out you had "reported" this chap to RCVS, I'd cease to be a client of yours pronto.

You remind me of another regular contributor to this forum who wants to report clients to the RSPCA whenever they fall short of certain ideal standards.

RE: Undiagnosed diabetic dog

Martin Atkinson — Fri, 04 Sep 2015 17:31:13 GMT

[quote user="Clare Tapsfield-Wright"]no one wants to report a colleague[/quote]I would edit that to 'no-one want's to need to report a colleague'. Sadly there are some who are so bad they should not be practicing and I can think of some I 'want' to report but hold fire and bite my tongue as it seems that the RCVS has varying standards and may see it as just sour grapes.

RE: Undiagnosed diabetic dog

Clare Tapsfield-Wright — Fri, 04 Sep 2015 15:24:53 GMT

I would agree with others , you may not have the full story here . the vet would not have run glucose tests had they not suspected DM and may not have written their diagnosis in the clinical notes that you have seen .

I understand from the OP that this is one of a series of incidents of treatment which have concerned you and it sounds as if you are worried about the competence of the other vet and their effect on an animal welfare basis and feel this is the final straw.

I would first of all phone the primary vet in a non confrontational manner and discuss the case if they are willing to do that. For all you know the dog may have been taken home having been diagnosed to say goodbye prior to PTS and then not represented as agreed , only coming in when the dog collapsed.

If there is genuine cause for concern once as many facts are gathered as possible then I would proceed to speak to prof con at RCVS and I am sure they will help advise. It may be that the vet is in difficulties and needs help and that is exactly what the performance and health protocols are there for.

no one wants to report a colleague but you would not have asked the forum if you were not very worried .

RE: Undiagnosed diabetic dog

Bob Russell — Fri, 04 Sep 2015 14:00:35 GMT

[quote user="Robin Grimmer"]

I agree. I don't think any vet can 'miss' something as simple to diagnose as diabetes with those blood results. You need to hear the other vet's side of the story. I worked in ooh clinic for 2 years and sometimes I saw cases that I thought may have been mismanaged. But it's easy to be critical when things suddenly crash ooh and you only have the clients side of events. I would always back up my colleague unless I had absolute evidence to the contrary.

[/quote]

Hence my suggestion to send complete and balanced clinical histories back to the primary practice. If someone has screwed up they may learn from it. If they have not and have tried to treat a pet properly they can mutter 'told you so' under their breath whilst drinking the first coffee of the morning.

I had a pi**ed off client with an elderly dog with absolute end stage ear disease. Have made it clear for months that a TECA is the only answer short of euthanasia. Lateral wall resection was offered as a second best earlier in the course of the condition. I even gave the owner a copy of the fixed price TECA mailing by one of the referral centres. Surgery declined on age of dog and cost.

All I could offer was big guns antibiotics but it became my fault when it became an abscess and seen by a budget practice. Checking my notes it is clear they are lacking in detail so guilty on that count but not on failing to advise the client.

Memo to self - try to write better notes in future!

RE: Undiagnosed diabetic dog

Martin Atkinson — Fri, 04 Sep 2015 11:32:35 GMT

[quote user="Jo Dyer"]I am a bit horrified by the tone of the OP. I have never met (in person, not 'heard of via hearsay';) another vet who was not caring, conscientious and adequately competent. Maybe I'm just lucky.[/quote]I think you've been incredibly lucky or are very naive. Not sure how meeting in person helps though, they're not likely to tell you that they don't care or are not competent, that information can only come from reports from elsewhere - when does that become hearsay? Sadly I can think of many, 2 of whom still work in surrounding practices!

RE: Undiagnosed diabetic dog

Robin Grimmer — Fri, 04 Sep 2015 11:06:26 GMT

RE: Undiagnosed diabetic dog

Jo Dyer — Fri, 04 Sep 2015 10:56:30 GMT

I am a bit horrified by the tone of the OP. I have never met (in person, not 'heard of via hearsay') another vet who was not caring, conscientious and adequately competent. Maybe I'm just lucky. However, my default would always be to assume that about my colleagues.

RE: Undiagnosed diabetic dog

Robin Grimmer — Thu, 03 Sep 2015 22:57:28 GMT

[quote user="Clive Ansell"]

No. Some practices and some colleagues are really bad at writing notes. I've seen many times lab results not written, conversations with clients not recorded

[/quote]

Definitely. And IME as a locum, solo practitioners and bosses in general are the worst offenders.! ;-)

RE: Undiagnosed diabetic dog

Nhombokisheni — Thu, 03 Sep 2015 22:29:15 GMT

What you should do is make contact with the said practice as part of feedback and ascertain the facts. Its been said in the past on this forum....don't always take things at face value. Have you actually witnessed what you say you are aware of or was this from third parties? Running to the RCVS and then being proved wrong can potentially leave you facing a legal backlash.....if you really feel strongly they have to be reported then advise the aggrieved clients to take the matter up themselves. Also keep every note of all they said to you and your responses......people have a way with words that might just surprise you. All the best.

RE: Undiagnosed diabetic dog

Clive Ansell — Thu, 03 Sep 2015 19:47:43 GMT

No. Some practices and some colleagues are really bad at writing notes. I've seen many times lab results not written, conversations with clients not recorded etc.

That aside, I would not entirely trust a copy of the clinical history given by the client; the practice may have given an edited version? the client may have edited it ? the client may have even made it up, after all a very small minority will lie through their teeth, and readily engage in insurance and internet prescription fraud.

Before considering reporting a professional colleague to the RCVS I would want both sides of the story, and would want to tick every box, dot every i and cross every t, which would include a copy of the clinical notes obtained from the practice and preferably speaking to the practice too.