Who would do a Caesarian?

RE: Who would do a Caesarian?

Hannah Wynne Richards — Wed, 27 Jan 2016 09:01:20 GMT

100% agreement

Wynne

RE: Who would do a Caesarian?

Virginia Campbell — Tue, 26 Jan 2016 23:18:07 GMT

I think I have said before on a similar discussion - I reckon top 3 things you don't get paid for:

- caesars

- parvo pups

- non client guilt inspired private cremations - never spent 5p on it in it's life, should've been euthed months ago, wait till it collapses then come in crying and wailing, agree to euth, elect private crem, cry that so panicked and shocked that the creature "suddenly" got into a euthanasable state that have left home with blue lights flashing and no wallet, tearful promises to scramble home and get cash or pay over phone, fail to answer mobile number provided for the next week till it gets packed off for group crem.

At least in the second scenario euthanasia is a more clinically indicated than for a caesar, usually; and for the third option you have "only" lost about half an hour of vet time, plus euthanasia solution, plus crematorium fee and for both there is no "evil vets made my animal suffer" (usually; the last parvo pup I had I gave a 50:50 chance to - it rallied then plummeted and needed euthed - owners paid up but then suggested that I had known the pup was doomed from the start but only admitted it for treatment to make money ).

The trouble with the Caesars with no money is that it's a PR disaster all ways up, especially since people equate it to humans- vulnerable, giving birth, cute wee babies, hard faced innkeeper turning Mary and Joseph away:

encourage them to go elsewhere: "Evil vets threw my bitch out in the snow"

offer euthanasia: "Evil vets wanted to kill my perfectly healthy dog cos no money upfront, even when I promised on my granny's life to sell my children's Christmas presents and bring the money tomorrow"

offer surrender: "Evil vets wanted to steal my dog and probably sell her and the pups for thousands"

hold till payment made: "Evil vets held vulnerable new mother to ransom in a metal cage with her ickle little babies while my child cried at home...and ONE DIED AT THE VETS so they obviously didn't bother caring for them"

I think you're better off to do the caesar with as much of a deposit as you can wring out of them and then if fit send it home, charge as normal and hound them vigorously for the balance if not reasonably swiftly forthcoming. That way, even if you don't get paid a penny, they will cry to all their impecunious wannabe breeder friends about how expensive you are and how ruthlessly you pursued them for money, hopefully without admitting that they didn't actually pay.

As somebody upthread wrote though, we can afford to do these once in a while - if we were getting 3 a week we'd be quicker to offer euthanasia as an option without a really substantial deposit.

RE: Who would do a Caesarian?

Rob Loxley — Tue, 26 Jan 2016 20:47:47 GMT

[quote user="David Mills"]I believe they are one of the biggest sources of bad debt at OOH centres[/quote]

Certainly were one of our biggest OOH debt sources

RE: Who would do a Caesarian?

Bob Russell — Fri, 22 Jan 2016 09:53:17 GMT

We received some bad Facebook press, this week. Someone arrived in reception with a 'stray'. Was checked for a microchip. As a result of RSPCA policy we insist that finders contact them to get a log number or pay for treatment themselves. Otherwise should we admit a cat or dog, there is no help with rehoming etc.

Sadly this became 'would not treat the animal unless we paid for it'.

We would deal with the caesarian first and worry about the payment later but would not make the owner aware of this! No money, no caesarean approach but we would still get on with it!

I got a 'free' boxer puppy from this very scenario!

RE: Who would do a Caesarian?

Hannah Wynne Richards — Fri, 22 Jan 2016 08:35:41 GMT

Linda That's really tragic. Another trick I've heard of, but not actually had to use is to get the owner to sign a form releasing the practice from all duty of confidentiality if the bill isn't paid within a week - and inform them that an advert would be placed in the local paper. That's a powerful threat in a small town

Wynne

RE: Who would do a Caesarian?

Braden Collins — Fri, 22 Jan 2016 01:10:31 GMT

Even with a tough line, we've never put a whelping bitch to sleep. We are able to access credit through a company called Vetpay where they only need a small deposit, so most qualify for this. I find that when you are very clear and firm on these things, people can almost always find the cash somehow.

Had this bitch not whelped herself and come in during normal hours, we would probably have done the procedure as the additional costs to us are limited to consumables.

We're in the middle of a parvo outbreak at the moment, with 1-2 cases each day between the two clinics. We're having to be tough on these every time as these are people who couldn't afford to vaccinate their dog, then expect us to do thousands of dollars of treatment for free/on a promise to pay. We have done a lot of free euthanasias for these, but none get admitted without a $500 deposit. Equally, those that have declined euthanasia (we push it very strongly if they can't afford treatment) and can't afford hospital treatment will get basic medical treatment.

RE: Who would do a Caesarian?

Linda Filshie — Thu, 21 Jan 2016 22:04:11 GMT

A litter of pups came under our care a few months ago.

The bitch whelped six pups naturally, then one got stuck. Another local practice PTS the bitch when the owner could not fund the c-section (no idea what the estimate was) and declined signing the dog over. I'm not convinced the euthanasia did much for animal welfare - three of the pups died over the following 2 weeks - linked to poor quality milk replacer I belive - and the remainder suffered badly with urine scalding.

RE: Who would do a Caesarian?

David Mills — Thu, 21 Jan 2016 17:21:04 GMT

We have these all the time, and we're usually last chance saloon. As others have said, we've never PTSd one - after the wailing and accusations following putting this on the table, the money appears (we insist on £200 minimum) magically. One the other night offered us double the money to not spay the dog at the same time.

I believe they are one of the biggest sources of bad debt at OOH centres (I assume because they're not covered on insurance). I do have some sympathy with the approach that the time spent wrangling about money, the dog could be done. As we're set up, we're here anyway and unless it displaces more 'profitable' work, recouping something from the procedure and cracking on may be a compromise worth striking. Where some of the OOH prices come from, however, is peculiar, and appears to be quite profit driven.

RE: Who would do a Caesarian?

Silvia Maldonado — Thu, 21 Jan 2016 15:37:29 GMT

Sorry, Stephen. I didn't make myself understood. I meant I would be "glad" to be fired standing for my professional conduct and my ethical believes, than for a cost argument like this one. If only she had gone home to make the payment once she were back and the caesarean done!

Faffing about trying to avoid a caesarian? not sure if you mean on the vet's side or the client. If on the vet's side, personally, I find safer, less risky, doing a C-sect when a dystocia is obvious, than messing around with medical treatment and manipulation. I advice my clients what I would advice my family or best friend. If on the client's side, I guess that past experiences (and cost sometimes, yes), worrier personality, "Dr Google"... take part in their decision?

As for estimations and cost, I wouldn't want to discuss them, when I don't own any practice and have no idea of the expenses I would have to cover. The opinion of those who do own practices is going to be of much value than mine.

Hope all this help clarifying my comments. Both the nurse and I spent most of last night wondering what happened to the bitch in the end

RE: Who would do a Caesarian?

grumpyoldman — Thu, 21 Jan 2016 14:32:17 GMT

[quote user="Clive Ansell"]OOH they can be bounced back to their own vet, or that vets OOH provider surely? as per our code of conduct.[/quote]

Yes in theory ,but they lie to get their foot in the door, this type of client lies a lot, they will often only tell you about the meds its on either just before or just after you have given it something, I have had them tear the Practice ID off the container but leave the name of the drug visible so that you cannot see where they have been previously. Sometimes you only find out on a monday morning when the discount outlet rings for a history. We have a database link on an I-PAD now to check registrations ,we were getting them lying about being registered several times a month, they will also use friends and relatives who are registered clients , they get seen them because we do not want to upset our own established clients.

Practically you either bite the bullet and send it all to vetsnow or get showered with everyone else's shite from time to time.

RE: Who would do a Caesarian?

Michael Woodhouse — Thu, 21 Jan 2016 14:30:52 GMT

What's a 'caesarian on the cheap'? We'd charge £500 ish plus the VAT. I'm making money on that. If you want to travel 2 hours then work is work.

I love a good caeser - the more the merrier. ;)

RE: Who would do a Caesarian?

Clive Ansell — Thu, 21 Jan 2016 13:00:34 GMT

[quote user="Anthony Dennison"]This is the crux of this discussion - you do it once, everyone will head over. My fiance's practice has low fees and they have people travelling up to 2 hours to come over OOH for caesarians because certain breeder forums mention them as cheap.[/quote]

In the nicest possible way it serves them right, if they choose to do OOH C-sections on the cheap then they have to expect to attract a certain standard of clientele. It also does nothing to discourage people from breeding and makes our profession complicit in this disgusting trade.

Travelling for up to 2 hours with a bitch needing a C-section, it could be argued, constitutes a welfare issue in itself. they could/should be redirected to their own or a closer practice.

RE: Who would do a Caesarian?

Clive Ansell — Thu, 21 Jan 2016 12:53:13 GMT

[quote user="grumpyoldman"]It happens all the time , the cheap and cheerful discount service people then try and send the scroats they have attracted in the day to VETSNOW at night ,with entirely predictable results ,they just start bugging and bad debting the other nearby practices that do not use vetsnow. [/quote]

OOH they can be bounced back to their own vet, or that vets OOH provider surely? as per our code of conduct.

RE: Who would do a Caesarian?

grumpyoldman — Thu, 21 Jan 2016 12:47:18 GMT

[quote user="Clive Ansell"]I find some of the fees quoted hard to get my head around; how can some sweatshop sh1t hole practice charge £65 for a spey, then OOH a C-section (a not dissimilar procedure) is £2000, more than a 30 fold difference - even factoring in that it is OOH, higher risk etc,how does one explain it to the general public ??[/quote]

It happens all the time , the cheap and cheerful discount service people then try and send the scroats they have attracted in the day to VETSNOW at night ,with entirely predictable results ,they just start bugging and bad debting the other nearby practices that do not use vetsnow.

RE: Who would do a Caesarian?

Anthony Dennison — Thu, 21 Jan 2016 11:59:41 GMT

[quote user="Clive Ansell"]If we take a softer approach, and get a reputation for it, we could end up with every hard luck sob story and no money C-section within a 50 mile radius. If we offer pts we are seen as money grabbing uncaring holes.[/quote]

This is the crux of this discussion - you do it once, everyone will head over. My fiance's practice has low fees and they have people travelling up to 2 hours to come over OOH for caesarians because certain breeder forums mention them as cheap.

RE: Who would do a Caesarian?

Robin Grimmer — Thu, 21 Jan 2016 10:32:49 GMT

[quote user="Michael Woodhouse"]

Tell me honestly - do you think you'd have been done in the same length of time if you'd taken £200 deposit, done the operation and let them pay the next day?

[/quote]

The trouble is in a OOH clinic you have to get payment up front because they are not a bonded client - you are never going to see them again and your bad debts would rack up and the OOH clinic would go out of business.

RE: Who would do a Caesarian?

Clive Ansell — Thu, 21 Jan 2016 10:25:43 GMT

[quote user="Braden Collins"]I would maybe be more inclined to do the Caesar during normal hours, but ooh means paying a nurse to come in, and I'm not prepared to lose that money on top of other losses. [/quote]

I agree, and if I had my own practice I would adopt the same approach.

It is difficult; none of us I feel want to euthanase a healthy bitch, but it does remain an option, and there is no reason at all we should not be paid for our work.

If we take a softer approach, and get a reputation for it, we could end up with every hard luck sob story and no money C-section within a 50 mile radius. If we offer pts we are seen as money grabbing uncaring holes.

I do think a message needs sending out though, that if you choose to breed and don't take responsibility and have the means to pay for a C-section it could end in PTS.

I find some of the fees quoted hard to get my head around; how can some sweatshop sh1t hole practice charge £65 for a spey, then OOH a C-section (a not dissimilar procedure) is £2000, more than a 30 fold difference - even factoring in that it is OOH, higher risk etc,how does one explain it to the general public ??

RE: Who would do a Caesarian?

Dagmar Steele — Thu, 21 Jan 2016 09:05:03 GMT

In my country we are obliged to give basic medical attention to any animal und threat of dying or suffering. Wether the owner is able/willing to pay is not relevant. Of course we are allowed to charge for it, but afterwards. Would a cesarian fall into this category? Rather yes than no because it's usually a good outcome at least for the bitch.

Apart from this I am with those who said they'd do it because I would also be guilt-ridden if I let an otherwise healthy bitch die or put her to sleep. Having said this I'd also set every wheel in motion to make the owner pay their bill.

RE: Who would do a Caesarian?

Braden Collins — Thu, 21 Jan 2016 08:42:35 GMT

As an update, the bitch whelped herself overnight so happy ending. I don't like the idea of keeping a bitch in post whelping as its a lot of extra nursing work, and I one had a bitch eat two puppies between doing a Caesar and the owner picking her up. Imagine the arguments that could cause if the owner thought they were going to sell the pups.

I would maybe be more inclined to do the Caesar during normal hours, but ooh means paying a nurse to come in, and I'm not prepared to lose that money on top of other losses.

We tend to find a hard line approach can be useful in the days of social media. Many local Facebook sites are full of people looking for a vet who gives credit, so you can easily attract more of these undesirables.

RE: Who would do a Caesarian?

Francisco Gomez — Thu, 21 Jan 2016 08:37:29 GMT

In cases like Silvia's, I guess the RCVS would expect you to euthanase the patient (given the choice) or let the client take the dog somewhere else (like in this case). I think I would have done the C-section and dealt with bosses' anger later.

The responsibility here is on the owner. And if they don't have enough to secure payment, we should be prepared to euthanase the patient.

Unfortunately I'm weak and stupid and I would've done the op, because of the feeling of blaming myself for not doing it. I guess some people might prey on that feeling.

Many PDSA clients have already learnt that you do not pay for spaying your dog. You bring your dog with a pyo and it is done for free thank you very much.

I see the point of Silvia (or Silvia's bosses), as well as Stephen's and Michael's. But all the CCTV in the world will only help you to ban the client in the future (maybe you'll manage to identify them and take them to court, I don't know). It is still very possible that the very same client (or their friend), will bring you another C-section when convenient if you have done the first one 'free'.

RE: Who would do a Caesarian?

Stephen Courtney — Thu, 21 Jan 2016 07:42:23 GMT

[quote user="Silvia Maldonado"]

I see your point, and agree with you in that, had it been my practice, I would have probably kept the bitch till the bill is sorted, or asked her to be signed over, or whatever.

I cannot comment about the fees, they are not my decision, I trust the practice owners know what are the best fees for us, the bills they have to cover, being near London, etc.

On the other hand, there was some mistrust on our behalf when over the phone she had no more than £200 in cash, then she had no more than £200 in total in her cards, suddenly she remembers she had exactly £2.000 in cash at home, then she paid over £200 with one card for the OOH+scanning+IV cath + O2... As things were, I needed a better reason for being fired than a client who is reluctant to go home and get the money she assures she has, while we were starting the caesarean, which would have been an easier solution.

[/quote]

If you are worried about being fired over a situation like this then you are working for the wrong company - good ECC vets are like hen's teeth! you are a professional, you have obligations under your RCVS oath and whatever vocation you hold in your heart - this isn't just a job (yet...) and if you feel it's best to do the op and hope for the best in the morning, that should be your decision.

Even if the client pays nothing, you are there, your nurse is there, and the true costs of the procedure are the consumables, plus the theoretical lost income of procedures you cannot do while dealing with the non paying case.

As Michael says there is often a lot more faffing about trying to avoid a caesarian than the actual procedure would take. I'm not a natural surgeon, and on the whole prefer to whelp naturally, but i learned the hard way after spending most of the night manually whelping a maiden 8 year old Great Dane and starting the Caesar at 4am....

I'm not sure Id be done and dusted as fast as he is though...

Regarding client saying she wasn't told about the payment requirements, we used to get a lot of this but now all phone calls are recorded. We also have CCTV in consult rooms that record and video each consultation which is invaluable in these disputes. People lie, end of.

There is no big brother attitude from management either - no one has time to snoop for the sake of it. these devices are a protection that sadly in this day and age is needed.

RE: Who would do a Caesarian?

Silvia Maldonado — Wed, 20 Jan 2016 23:49:50 GMT

I see your point, and agree with you in that, had it been my practice, I would have probably kept the bitch till the bill is sorted, or asked her to be signed over, or whatever.

I cannot comment about the fees, they are not my decision, I trust the practice owners know what are the best fees for us, the bills they have to cover, being near London, etc.

RE: Who would do a Caesarian?

grumpyoldman — Wed, 20 Jan 2016 23:39:49 GMT

Sometimes you are stuck between a rock and a hard place with these people . We would probably charge £550 for a day time c/section and £700 OOH . But we find that is just as big an obstacle as 1500-2000 sometimes . We also have a practice a few miles away that does it for 300-400 OOH . Not sure how they can pay decent wages and make any money out of it ,but it does have the saving grace of attracting a particular type of client you would rather not have in the building anyway.

If someone else want to work for nothing and attract these clients ,probably better to just let them get on with it .

RCVS will not get involved because their is no conduct issue here, its fees ,and you have addressed the welfare options one of which was euthanasia .

RE: Who would do a Caesarian?

Michael Woodhouse — Wed, 20 Jan 2016 23:33:42 GMT

Silvia - sounds like a pain in the arse, but the problems are all over the money and getting it now. I see how it has to be different with an OOH service but £1500-2000 is a lot of money for a 30 minute operation! I like to get the bitch home as soon as I can after surgery - If I was called in a similar situation at 2am - I would be confident I'd be back in bed by 3.45 with bitch and puppies at home.

Tell me honestly - do you think you'd have been done in the same length of time if you'd taken £200 deposit, done the operation and let them pay the next day?

Is there anywhere other than a fast food restaurant where you are expected to pay upfront? Even at the petrol station I get to put the fuel in the car before I have to pay for it!

RE: Who would do a Caesarian?

Silvia Maldonado — Wed, 20 Jan 2016 23:18:21 GMT

I'm glad to see how many answers about this subject have been posted. Just last night we had a horrible case of a C-section and no money. Neither the nurse nor me could sleep afterwards, and we still wonder what happened to the bitch. Long story, easier to copy&paste the notes (for you who have some extra time to read it), and none of us would have PTS her, despite we spoke of that. Last resort would have been signing her over to us, or whatever. And my case is going to end in a complaint, lawyers involved if the client keeps her threats.

Anyone would have done something differently? What's been your options in similar cases? Here is the story:

HX: O called by 2am informing A's been panting since 22h. Asked if changed behav, and confirmed hypoxia, also seen vaginal discharge since midnight. O saw A pushing (parturition) b4 and after discharge, last time seen pushing when on their way here in the car. A was mated several times, her time is due now, has had 2 litters b4, last one with giant pup but able to pass it with IM oxytocin. OOH fee discussed over the phone, cost is a concern.

CLIN EXAM: v distressed, no Ferguson reflex on presentation, panting+++, HR 152bpm, temp 38.0C, MM pink, CRT <1s. Greenish vulva discharge, on vaginal palp felt placenta in pelvic canal, O present, glove with vaseline stained with discharge. Unable to check pelvic dilation due to foetus/placenta position, still no Ferguson reflex. V heavily pregnant.

DDX: O v concern of sx approach (C-sect). Discussed abdom scanning to rule in/out foetal distress, necrotic foetus, dead puppy, poss uterine rupture (free fluid), to help making decision. Offered as option medical tx (IV calcium and oxytocin combination) instead of C-sect. O happy with scanning and making decision according to results.

US confirms several puppies alive (min 4, adv O scanning is not reliable for counting puppies, after O's request), all HR present, 2 of them <200bpm. Unable to assess condition of pup in pelvic canal (surrounded by bones). O informed of risks to puppies due to stress, not seeing A in pushing position or labouring at any moment.

DISCUSSION with O: O really concern of sx risk for A. Discussed pros and cons of sx, offering again medical tx, giving estim for each option. O is given time to discuss both options with friend, while placing IV cath on A (needed for whichever option O may decide). As discussion is taking longer than expected, A is placed on an O2 cage, where she calms down+++, sitting down and stopping panting (never seen labouring). O is informed A stopped panting in O2 cage and is calmer, but a decision needs to be taken. Discussed trying Ca+oxytocin for half hour (estim £300-£500, icl OOH and US), then C-sect if no results (estim £1500-2000, incl OOH, US, medical tx). O opts for C-sect straight away, to reduce risks for litter. O is informed all meds are off-licensed for C-sect and will need O’s consent, which O agrees, aware of risks for bitch and litter, and signed consent for procedure and off-license meds.

While preparing IV fluids, nurse vet LO asks me to speak to O, who insist was not informed payment needed to be sorted tonight, reporting O has several cards but no more than £200 in total. After checking A is stable in O2 cage (sat, not panting, not labouring, QAR), discussed payment again with O. LO explains it is BVE policy take deposit prior to performing procedures, despite O understands it should be our decision, as manager is not present on the building. O request contacting manager/owner, who unfortunately is abroad and unavailable. O insisted she had £2.000 in a safe box at home, promising sorting the bill in the am. O understood bringing a card would be enough. Adv collecting deposit tonight and coming straight back, while we make all ready for sx, start A on IVFT, O2 therapy, to reduce risks and innecessary suffering. O declines option, wishing starting on C-sect tonight, sorting invoices in the morning (O needs staying at home with children)

Situation becomes more diff as O believes we are misleading her, not mentioning over the phone deposit and bill should be sorted out tonight, we care more for money than animal welfare. We offer O listen again the recorded phone call, after not agreeing with discussion over the phone. O is informed that, according to animal welfare, we shouldn’t leave A suffering, and A will not be denied first aid and pain relief. At this point (money a big issue) offered two other options: euthanasia or discharge against vet advice, which only worsen situation, O threatening to investigate these last comments through lawyer.

As both LO and myself are reluctant to perform euthanasia due to financial restrictions, stressed the option of discharging against vet advice (O aware any pain relief is off-license, will not solve the problem, and high risk for litter). O and friend opt for calling another vet (Elisabeth Smith), who accepts taking over the case. O signs the consent form (discharge against vet advice), IV catheter is removed for safety reasons, O takes A to ES, after reminding us they will investigate if vets have the right of putting animals to sleep under animal welfare act. O leaves the practice by 3:45am aprox

TX: only tx given to A was O2 therapy.

OUTCOME: O declines any other tx, as also declined signing the off-license consent form (discussed with SM, and given time to read it in waiting room). At time of discharge A is QAR, RR 48bpm, not panting, not labouring