Dental analgesia

Re: Dental analgesia

Gillian Mostyn — Wed, 19 Jan 2011 11:59:03 GMT

[quote user="David Beattie"]I would not be confident enough in my own clinical knowledge being beyond reproach that I would find myself in a position to cast the first, or perhaps any, stone [/quote]

I think that's the point. By saying, both on his website and in his disciplinary hearing, that he feels his methods are the ONLY way to go and that he is ABSOLUTELY correct, he is the one who needs to learn a little humility. It seems from this forum the rest of us do accept the limits to our knowledge and abilities.

Re: Dental analgesia

Anonymous — Wed, 19 Jan 2011 10:59:15 GMT

Apologies. Didn't mean to suggest that the vast majority of vets were incompetent (although I see that is how post came across), merely that I would not be confident enough in my own clinical knowledge being beyond reproach that I would find myself in a position to cast the first, or perhaps any, stone (as a previous post put it). I accept that it's not on for me to infer that other members of the profession might be in a similarly vulnerable position.

Re: Dental analgesia

Bob Russell — Wed, 19 Jan 2011 10:55:03 GMT

None of us are perfect, nor can we be expected to be. The key thing we should all aim for is to know our limitations and make sure our patients suffer as little as a result of it! This is where asking for advice comes into its own.

I am sure every one of us has our own foibles and little ways and close scrutiny may be a little uncomfortable. The vet that stops questioning what he is doing is a vet that has stopped learning.

An arrogant or 'know it all' vet is a dangerous thing as is the arrogant doctor!

Re: Dental analgesia

Richard Carter — Wed, 19 Jan 2011 10:43:54 GMT

Ask not for whom the bell tolls.....

Re: Dental analgesia

Hannah Wynne Richards — Wed, 19 Jan 2011 10:21:22 GMT

Reading his web site, he certainly seems inclined to reach for the scalpel at any and every opportunity-and the broadly based criticism of the rest of the profession, on a site intended tobe read by the public is extremely unprofessional tomy (admitedly old-fashioned ) mind

Wynne

Re: Dental analgesia

Vikki Halliday LLB — Wed, 19 Jan 2011 10:11:46 GMT

[quote user="David Beattie"]put under such a weighty microscope we may not fare much better[/quote]

Ah but therein lies the rub! We are what we are and we do what we do, but the "test" if you like, so far as the DC are concerned anyway, is what would 99% of vets do in the circumstances.

I'm truly convinced as you are David that my clinical judgements and policies if put under the "weighty microscope" would potentially be found wanting in certain ways. However I am prepared to accept where I can learn, where my knowledge is sparse, where the limits of my knowledge are, and I think that, with due respect, was one of the failings of Mr Holmes. By all accounts, his opinion of himself was that his knowledge and experience were second to none, and that the rest of us are all wrong.

I chose three statements which appeared to me to be without foundation, misleading, and paradoxical. That is not really an in-depth analysis.

I however am regularly proved wrong, and will happily admit when I am.

Re: Dental analgesia

Bob Russell — Wed, 19 Jan 2011 09:51:34 GMT

It appears that all dogs with itchy bums should have anal glands removed. All dogs with ear problems should have aural resections and sometimes the only sign of bad teeth is poor grooming. WOW!

What a useless vet I must be as I do not agree with any of this clap trap!

Discuss (more)!

Re: Dental analgesia

Anonymous — Tue, 18 Jan 2011 23:10:02 GMT

aromatherapy should be as good as anything in stopping a herpesvirus becoming a retrovirus (see http://en.wikipedia.org/wiki/Virus_classification#Holmes_classification). I feel Mr Holmes misunderstandings have spent enough time being dissected in public, I'm pretty convinced that for the vast majority (or if you won't buy that, at least a significant minority) of vets if we had all our clinical beliefs and practices, not to mention each and every individual consult, piece of advice or treatment put under such a weighty microscope we may not fare much better.

Re: Dental analgesia

Vikki Halliday LLB — Tue, 18 Jan 2011 22:50:48 GMT

I was also astonished to see some of the following statements on the website........

Re: Cat Flu

We get good results by using aromatherapy on some of our patients with cat flu to stop the condition becoming chronic.

(Really? I've not yet heard that aromatherapy can stop FHV becoming a chronic retroviral infection)

Re: Feline dental work

It is virtually impossible to brush a cat's teeth on a daily basis, so you should always budget for a minimum annual dental descale, (at the time of vaccination booster).

(Annual descale!? Gosh, what are they feeding these cats!?)

Re: Insurance

(1- from the Dog page)

HEALTH INSURANCE.

Legally, we are unable to recommend a particular Pet Insurance Policy

(2 - from the Cat page)

PET INSURANCE.

We recommend Pinnacle LIFELONG Pet Insurance

Re: Dental analgesia

Mark Hedberg — Tue, 18 Jan 2011 22:05:07 GMT

[quote user="Gillian Mostyn"]

Incidentally, have a look at his website, especially the following page. Enlightening.

http://www.walthamvets.co.uk/referral_proc.asp

[/quote]

Well, that's certainly one way of looking at referrals...

Re: Dental analgesia

Michael Woodhouse — Tue, 18 Jan 2011 21:46:19 GMT

[quote user="Evelyn Barbour-Hill"]They very often look better when anaesthetised. I don't know why.[/quote]

Reduced blood pressure, less obvious gingivitis?

Re: Dental analgesia

Anonymous — Tue, 18 Jan 2011 21:41:35 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="David Beattie"]

Just had a pug in which was referred about 6wks ago for a chronic unilateral nasal discharge. The supervised resident diagnosed bacterial rhinitis secondary to dental disease with CT showing that the left canine tooth root appears to grow into the left nasal cavity with dorsal direction. The nasal discharge (which had resolved on amoxicillin) has returned as expected, and the owner is making arrangements to travel back to the referral centre for treatment.

I thought this was topical as they plan to do a soft palate resection at the time of the dental (hence my absolute reluctance to remove the affected tooth here!). Not clinically affected, doesn't even snore, but had bradycardia and respiratory arrest post-extubation when in for initial assessment and thought might be due to long soft palate and would be safer to resect this prophylactically prior to future GA recovery.

[/quote]

Ve-ry inter-esting.

Why did they not extract he tooth the first time?

[/quote]

I can but speculate. But before dong so I re-read my original post and want to clarify. I do actually think the resident was supervised (with the supervising specialist [soft tissue surgeon] signing the letter also) and wasn't trying to imply that I thought the case management was in any way sub-standard. Indeed, the referral establishment (which happens to be a uni with a relatively recently refurbished small animal hospital) has never failed to impress ether myself or the (admittedly few) clients who have journeyed there. I hadn't picked up on the upper canine being a problem; I only saw the dog as a second opinion from another practice which had failed to respond at all to 2 short courses of antibiotics, it had no air flow down one nostril and after taking a swab for C&S and cytology (finding only Strep canis and non-specific cytology), I dispatched it down to a referral centre (on amoxicillin) rather than waste time with aspergillus serology (the only other thing I could do conscious) or GA/sedation for intraoral radiographs (and we don't actually have dental x-ray...). They saw it that week and under GA did a CT scan, rhinoscopy and nasal biopsies. On extubation, it developed a profound bradycardia, respiratory arrest and was given atropine, but that's all I remember from the referral letter regarding anaesthetic details (but again I have no reason to believe the anaesthetic was ether poorly managed or monitored). I think the client mentioned that the dog (5 yr old) had previously had a GA uneventfully.

My speculation for not removing the tooth at the time is that the initial suspicion on CT scan was of neoplasia (which I was subsequently told is uncommon in brachycephalic breeds), and it was only after the CT scan had been reviewed by a specialist diagnostic imager, that the suspicion was shifted to the offending canine. Again this seemed pretty reasonble to me, and on examining the mouth conscious y'day, I'd confess that I was struggling somewhat to fgure out which of the rather jumbled teeth was the offending one (I think the canine was actually situated caudally adjacent to 1st premolar, but I'm not honestly not 100% sure...)

An alternative explanation for their reluctance to remove the tooth was that they were waiting on a pending outcome from a couple of disciplinary hearings they had caught wind of:

2 vets had examined the mouth and declared to the owner the teeth were fine, so perhaps they were nervous about the implications of extractions without a fullly reported specialist-interpreted CT scan to back up the decision
there was an overlong soft palate (which the client assured me has never previously, nor since, been of concern)

Re: Dental analgesia

Evelyn Barbour-Hill — Tue, 18 Jan 2011 20:53:06 GMT

[quote user="Kate Richardson"] I have often looked at the mouth once the animal is asleep and they appear significantly improved to the point where I have questioned myself- why did I book this cat/dog in for a dental![/quote]

Yes, me too. They very often look better when anaesthetised. I don't know why.

[quote user="Kate Richardson"]and antibiotics again make a significant clinical improvement.[/quote] You sure of that?

Re: Dental analgesia

Gillian Mostyn — Tue, 18 Jan 2011 20:45:36 GMT

Yes - I also read it differently to Vikki. I think that rather than being in any way humbled by the poor outcome of his clinical case, or open to the possibility that his methods MAY be flawed, he instead felt that he had done nothing wrong at any point. I think it was the arrogance that annoyed the DC and made them feel that judgement had to be carried out immediately, not the vigor of his defence.

Incidentally, have a look at his website, especially the following page. Enlightening.

http://www.walthamvets.co.uk/referral_proc.asp

Re: Dental analgesia

Evelyn Barbour-Hill — Tue, 18 Jan 2011 20:44:51 GMT

[quote user="David Beattie"]

[/quote]

Ve-ry inter-esting.

Why did they not extract he tooth the first time?

Re: Dental analgesia

Evelyn Barbour-Hill — Tue, 18 Jan 2011 20:40:34 GMT

Is he not supposed to defend, vigorously if he wishes, his actions? Is it not right and proper that he should do so?

What "insight" exactly was he supposed to show and how was he supposed to show it?

Perhaps the DC could issue us all with a little booklet on the best way to grovel if you find yourself up on a charge.

Re: Dental analgesia

Rob Loxley — Tue, 18 Jan 2011 20:26:04 GMT

[quote user="Vikki Halliday"]

I am however a little concerned by the closeing statements where the DC decided that Mr Holmes was not to be believed because he vigorously defended himself, and it does on the face of it seem a little like the decision was made based on the man's personality traits!

[/quote]

Hmm, from my reading this comment is not made with reference to deciding on the outcome of the charges, but on deciding the sanction to be applied.
The quotation in full is "The Committee is however also mindful of Mr Holmes’ conduct during the previous 11½ days of the Hearing, during which time his every action was vigorously defended and no insight whatsoever was shown". It is taken from a paragraph discussing whether postponement of judgment would be appropriate (i.e. allow him to continue to practice but with conditions - as per his previous sanction) and in determining that this was not appropriate. This seems reasonable to me.

Re: Dental analgesia

Hannah Wynne Richards — Tue, 18 Jan 2011 17:58:41 GMT

I notice you are rather coy, saying "There has been a nasty habit on the part of some universities employing clinicians as residents then providing them with little support "

Are you like me lacking sufficient proof to risk bankruptcy for naming and shaming, but (in my case ) with enough suspicion to avoid some referral centres

Wynne

Re: Dental analgesia

Malcolm Ness — Tue, 18 Jan 2011 17:18:36 GMT

[quote user="Hannah Wynne Richards"]but I don't have your faith in the supervision of residents in many referral centres[/quote]

It isn't faith, it is the rules. If you have evidence that a "resident" is working without supervision then you should complain first to the centre but copying in the responsible authority (RCVS or one of the European Colleges). There has been a nasty habit on the part of some universities employing clinicians as residents then providing them with little support. Regrettably, in the field of SA surgery, Italy and UK are not above criticism.

My resident signs all referral letters for cases that he has been involved with but my name is always there as well. The buck stops here!

Re: Dental analgesia

Hannah Wynne Richards — Tue, 18 Jan 2011 16:51:32 GMT

So when is an unnecessary staphylectomy unnecessary? It shouldn't depend on who's doing it-any more than a refusal to attend for a house visit OOH

I've done lots of pug anaesthetics,and yes they are VERY closely supervised post-op, but an automatic soft palate resection!!!!!!!!!!!!!!!!!!!!!!!!!!!

Which referral centre was this ?, and did they extubate too soon?

Wynne

Re: Dental analgesia

Anonymous — Tue, 18 Jan 2011 16:43:34 GMT

Re: Dental analgesia

Hannah Wynne Richards — Tue, 18 Jan 2011 15:34:01 GMT

I can't agree more with you Malcolm where OOH supervision is concerned-in fact poor OOH care is the reason I avoid 1 locally based RCVS Specialist

My referral centre of choice has a high ratio of Specialists to residents/interns, but I don't have your faith in the supervision of residents in many referral centres-my opinion is they are often being relied on for much of the referral work in some places-which I avoid. I'm totally with you that they should be under 1 to 1 supervision

Yes I do know the difference between Specialists and generalists, but if unable to persuade owners to travel to my 1st choice centre, then it's a case of choosing the best option the owners will allow me-my worry about this ruling is that owners will be presented with a choice of referral centre or PTS

Wynne

Re: Dental analgesia

Malcolm Ness — Tue, 18 Jan 2011 15:20:51 GMT

[quote user="Hannah Wynne Richards"] only referral centres should perform staphylectomies-there are some 1st opinion practitioners who are more than capable.[/quote]

Throughout my career I have held the opinion that any veterinary surgeon should be permitted to perform any surgical procedure, no matter how complex PROVIDED they have properly informed consent from the owner. The gaining of properly informed consent includes a detailed discussion of the training, experience, and qualification of the surgeon as well as those of other available (referral) surgeons along with a sensible appraisal of what those differences might mean. I am seeing increasing numbers of cases where the client has been misled by a vet talking up their own expertise or talking down the difference between themselves and a trained surgeon.

Wyn raises a couple of points - first nobody should be referring to a resident at a referral centre. All properly regulated residencies involve close, one-on-one supervision of a resident by a [specialist level] supervisor. Second, while the ex RSPCA surgeon might well be competent, but unless he has had his credentials reviewed and his ability examined then we really can't know. Even with a Cert, the chap is at least 3 years of full time supervised training/study behind a diplomate surgeon - this massive disparity between a self-taught enthusiast and a properly trained surgeon is not well understood by most general vet practitioners. To put it into focus, my current resident will spend as many hours studying just SA surgery during his residency as he spent studying absolutely everything during his 5 years at vet school. (he had a cert SAS before he started the residency). My experience as a surgeon and examiner at several levels indicates that while confidence is widespread and relatively common, competence is less so and correlates pretty closesly with qualifications.

Specifically wrt soft palate resections: many practices now use deputising services and many more have infrequent and intermittent supervision of patients overnight. Relatively few have constant vet supervision which is what I (and I suspect almost all clients) would consider the minimum level of care for a dog immediately following airway surgery. Not only do I think it would be foolhardy to attempt such surgery without proper training, I believe it would be rash to do the surgery without adequate aftercare provision.

Re: Dental analgesia

Hannah Wynne Richards — Tue, 18 Jan 2011 14:35:10 GMT

4 attempts at staphylectomy in 1 dog is well OTT, and unnecessary surgery undertaken for any reason is definitely disgraceful professional conduct, so if they had just said that, and struck him off for it, I would have been with DC Either he's doing unnecessary staphylectomies, or I'm missing an awful lot who need it-and my waiting room isn't full of choking, breathless dogs!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1

I dofeel,however that they have rather over-iced the cake-which makes me uneasy.Acat with gingivitis is not normal, and proper dental examination in a concious cat is impossible

2 other points which make me uneasy are the implication that only referral centres should perform staphylectomies-there are some 1st opinion practitioners who are more than capable. I have a neighbouring veterinarian, who worked in an RSPCA hospital for some years, after graduation.The financial situation of the owners meant that they could not afford even normal fees,let alone referral,so he became proficient at challenging surgery, and I would far rather refer to him, than a resident at a referral centre

Also, as Vikki says, if a robust defence is to be a reason for a more severe penalty, then innocent veterinarians who are wrongly, and maliciously accused may be scared of defending themselves

Wynne

Re: Dental analgesia

Kate Richardson — Tue, 18 Jan 2011 10:31:49 GMT

[quote user="Hannah Wynne Richards"]

What exactly was the inappropriate and out of date treatment which was previously carried out?

Wynne

[/quote]

I want to know too!