Exlap?

Re: Exlap?

Helen Wallace — Wed, 11 Jan 2012 11:38:23 GMT

[quote user="Wren"]

Out of interest how does one persuade a dog to eat cotton wool? Do you mix it up with dog food? Even dogs that chose to eat the most bizarre FBs can become rather suspicious when they think they're being made to eat something odd. Or are they all labs and there is no problem?

[/quote]

The recommendation I found advised soaking it with gravy. We didn't have any so shredded the cottom wool into small pieces and covered it in sardine juice (some tins in the cattery). I was a bit skeptical but it didn't touch the sides. We followed it up with w/d and when nature took its course fragments did indeed pass out wrapped in the cotton wool.

I was unaware of the DC case at the time this happened. Would it have altered my thinking? I don't know. We kept the dog in and monitored passage by x-ray. The owners were warned of risk of perforation and I was somewhat nervous for the next few days but it did turn out well.

Re: Exlap?

Wren — Wed, 11 Jan 2012 10:42:36 GMT

Re: Exlap?

Michael Woodhouse — Tue, 10 Jan 2012 12:04:01 GMT

[quote user="sarah mason"]

had similar situation at christmas dog ate a piece of ceramic bowl and was given apomorphine. 3 days later pneumomediastinum and a hole found just caudal to the pharynx. doing fine now but was at least 3cm and very sharp woul have needed gastrotomy otherwise as probably would have caused carnage in the intestine

[/quote]

I agree with the earlier idea that the bowl would probably have passed through the gut slowly in a controlled manner, but the violent act of vomiting more likely to do damage.

I've always gone with wait and see with these things, can always intervene later. Check the dog myself 24 hours later.

Re: Exlap?

Hannah Wynne Richards — Mon, 09 Jan 2012 15:22:56 GMT

Informed consent is really the issue-some veterinary surgeons won't offer referral if they think the owner can't afford it

Wynne

Re: Exlap?

Judith Joyce — Mon, 09 Jan 2012 14:59:13 GMT

[quote user="Bob Russell"]Often the vet just has to do the best he or she can under the circumstances even if it pushes the boundaries of competence. It may not be perfect but there may be few affordable alternatives.[/quote]

I have no problem with that (and in fact, I have helped defend practitioners against legal action in such a scenario). However, the key is informed consent - was the owner made properly aware of the limitations of the surgeon/surroundings etc, and the availability of other options, before agreeing to treatment. More and more I am seeing cases with a poor outcome (due to poor treatment) that have been treated without the owner being made fully aware of the whole situation or the alternatives available. Expense is used as an excuse as often as it is a reason - most of the fracture revisions I see would have been charged a similar amount by us was charged by the primary surgeon for the first attempt and unlike most of the primary surgeons, we carry the cost of revising any of our cases that need it.

Malcolm N

Re: Exlap?

Hannah Wynne Richards — Mon, 09 Jan 2012 12:57:50 GMT

It doesn'tmake it any better for the animal-but when the owners have declined sugery/referral on grounds of cost-they also have to bear moral and legal responsibility for adverse consequences

I'm now scared of legal consequences of operating,and scared of medical consequences(though less so since reading this thread ) of leaving

Wynne

Re: Exlap?

Bob Russell — Mon, 09 Jan 2012 12:43:24 GMT

It must be remembered that the ultimate in experienced intervention is frequently outside the pocket of an owner. Throughout my working life I have seen and done interventions with prior study and a book open because the surgeon has not performed a procedure before.

Often the vet just has to do the best he or she can under the circumstances even if it pushes the boundaries of competence. It may not be perfect but there may be few affordable alternatives.

I cannot comment on the particular case above because I know only the basic details.

Re: Exlap?

sam aldridge — Sun, 08 Jan 2012 00:06:27 GMT

Sorry about formatting - am on my iPhone :)

Re: Exlap?

sam aldridge — Sun, 08 Jan 2012 00:03:29 GMT

A senior vet that was willing to come in if the shift had been difficult and busy ( which it was). This was told to the nurse (and I believe the vet). An on call manager if they felt uncomfortable disturbing the senior vet. This person may not have been in a position to come in themselves (geography etc) but is there to help make decisions such as extra staff/help contact senior staff members/authorise rates for extra help etc. The nurse worked at another close by vets now clinic. She was on the phone to myself during the op. When asked if everything was ok (was asking re blood transfusion on another case) replied yes. If the answer had been no I'd have organised help (again prob the senior vet.) None of that help was taken. That doesn't absolve any deficiencies found in the handling of the case, nor does it impact on any opinion about whether he should have applied for or been given the shift. But it is unfair to say no back up. There are in fact 40 odd other clinics you can call for advice at any time as well, at the time one hospital and the rads could have been sent to the us (stat reply 1 hour) for an expert radiologist opinion. There is always more to a story. None of the above changes the other questions as noted previously, but there is always some help available.

Re: Exlap?

Judith Joyce — Sat, 07 Jan 2012 23:53:55 GMT

[quote user="sam aldridge"]Without wishing to comment too much, knowing those involved in the case- there was back up there, very willing, competent back up- if only it had been asked for at the time. Why it was not is not something that was investigated, neither was what back up was in place. There were actually several avenues of back up, none of them were used sadly[/quote]

Describe the back up that was available - innuendo is unhelpful.

Malcolm N

Re: Exlap?

sarah mason — Sat, 07 Jan 2012 23:29:04 GMT

Re: Exlap?

Helen Wallace — Sat, 07 Jan 2012 21:38:32 GMT

Just found this thread. I've just had a staffie eat fragments of a broken glass jar- showed up beautifully on x-ray. Discussed all options with o. Didn't want to induce emisis as I figured too high a risk of oesophageal damage. O wasn't keen on exlap re cost so we went for cotton wool and w/d and very close monitoring.

Despite my cold sweats it worked like a charm- all glass egested 2 days later wrapped in cotton wool. Relieved vet, happy owner and dog doubtless looking forward to its next foreign body experience :)

Re: Exlap?

sam aldridge — Sat, 07 Jan 2012 20:09:24 GMT

Without wishing to comment too much, knowing those involved in the case- there was back up there, very willing, competent back up- if only it had been asked for at the time. Why it was not is not something that was investigated, neither was what back up was in place. There were actually several avenues of back up, none of them were used sadly

Re: Exlap?

Mark Holmes — Sat, 07 Jan 2012 19:43:43 GMT

[quote user="Lorna McHardy"]

... and reading the full report does put rather a different slant on things!

It confirms for me that it isn't about making the right or wrong decision (provided the decision can be defended and coincides with what most other competent vets would do under the circumstances), but about carrying through the decision you do make with sufficient competence. Plus, reading the conditions the guy was expected to do the job under, I feel very sorry for him, and think VetsNow should have been reprimanded as well for poor management and inadequate staffing.

[/quote] Yes I have said that before. To position yourself as a provider of specialist emergency care and promote the service they do, and then employ under qualified staff sole charge. Hmmmm they bear some responsibility, particularly if they were fully aware of the vet's position. If nothing else they are guilty of false advertising.

Re: Exlap?

Lorna McHardy — Sat, 07 Jan 2012 19:19:03 GMT

... and reading the full report does put rather a different slant on things!

Re: Exlap?

Lorna McHardy — Sat, 07 Jan 2012 18:54:51 GMT

found it

Re: Exlap?

Lorna McHardy — Sat, 07 Jan 2012 18:54:49 GMT

found it

Re: Exlap?

Lorna McHardy — Sat, 07 Jan 2012 18:50:01 GMT

[quote user="Judith Joyce"]

I would urge everybody to read through this case in some detail before jumping to conclusions.

Malcolm N

[/quote]

Where would I find this?

Re: Exlap?

Lorna McHardy — Sat, 07 Jan 2012 18:40:01 GMT

[quote user="Will McMullan"]

On a side note, what are people's opinions on inducing emesis if ingestion is known to have been recent? I probably would, especially if the current thinking is now that the glass will safely travel the whole length of the GI tract in the other direction.

[/quote]

When I was a student seeing practice, a woman brought a collie in, in a right state (the woman, not the collie), and just kept saying he had swallowed a bedsheet. So the vet induced emesis, and sure enough, up came an entire bedsheet, a little torn. When asked if she had any idea what had made the dog swallow, of all things, a bedsheet, the owner blushed deeply and said "I think he was jealous"

Re: Exlap?

Lorna McHardy — Sat, 07 Jan 2012 18:33:17 GMT

[quote user="Hannah Wynne Richards"]

I also feel that Dick's unreserved condemnation of surgery before peritonitis has developed has moved the goal posts

[/quote]

Was this a general comment on all cases of glass or even FB ingestion, or a comment on the particular case under discussion? Because it seems to me that if an owner tells you his dog has swallowed something you think has a reasonable chance of passing without causing any damage (light bulb in a labrador, for instance), then that's quite different from when an owner tells you his dog has swallowed something you think has no chance of doing this (I dunno... whole pair of glasses in a CKC?).

My point being that surely, whatever your patient has swallowed, you will make the decision to wait or operate based on a)what the owner tells you, b)what the x-ray tells you, and c)what your experience tells you. If, within those parameters, you act reasonably in a way that can be defended, you should have nothing to fear from an enquiry.

I've been thinking about this, and it seems to me that the only reason for operating would be a near-certainty that it will not pass; since surgery itself opens up the risk of peritonitis (amongst other things). But if, for instance, I x-ray a dog and find a radio-lucent object bigger than the lumen of the gut, I'll operate whether it's symptomatic or not - unless someone can give me a very good reason not to.

It sounds as though this vet was not actually qualified to make that decision in the first place, and then bungled the operation almost as a bonus...which is a different thing altogether and explains why he ended up in front of the DC. I would hope that someone who is qualified and can justify his decision, should not be worried.

Re: Exlap?

Judith Joyce — Sat, 07 Jan 2012 18:03:56 GMT

[quote user="bob lehner"] but surely not necessarily negligent.[/quote]

the disciplinary process is about professional conduct. Whilst negligent practice would certainly make it difficult to defend yourself in a disciplinary hearing, negligence itself is decided by the courts and not the RCVS.

[quote user="bob lehner"]we can't possibly refer every single tricky case[/quote]

........ nobody has suggested that and you are going off at a tangent. However, if you recognise a case as being "tricky" relative to your own experience, ability and resources then go on to treat that case without discussing other options, including referral, with the owner then you are skating on very thin ice.

Malcolm N

Re: Exlap?

bob lehner — Sat, 07 Jan 2012 17:24:58 GMT

[quote user="Hannah Wynne Richards"]Before the DC hearing I would have operated, but now, if that is the dog that goes on to develop peritonitis, I'd rather the complaint to RCVS was about one of their own specialists-not about me[/quote]

But we should not all lose sight of what constitutes 'negligence'. To quote from the VDS website:

'WHAT IS NEGLIGENCE?
To prove you have been negligent a person must show:
- that you have done something that no responsible body of veterinary surgeons would
have done in the same circumstances, or
- that you have failed to do something that any responsible body of veterinary surgeons
should have done in the same circumstances.
It follows that, in many ways, it is the profession itself that decides what is negligent and what is not. That
is the reason for judges relying so heavily on expert professional opinion in deciding cases. It also explains
why we often need to obtain expert veterinary opinion when handling a claim.
Experts need to be aware that it is not what they would have done in a certain situation that is important.
The critical question they need to answer with regard to what the veterinary surgeon is alleged to have
done negligently is:
Was it outside the range of what could be regarded as reasonable veterinary practice at the time?'

One of the things I find most interesting on these forums is the amazing disparity of views that turn up - even on the most basic things we all do on a daily basis - such as what type of ligature to us in a bitch spay. It seems to me that an experienced v.s. should not be considered negligent in his/her properly considered decision as to whether to operate or not on a dog which, for example, had swallowed glass. If you were very inexperienced and/or out of your depth then I guess that is a different matter and you should recognise your inadequacy and if possible defer to someone with more knowledge/skill.

Let's be honest - we can't possibly refer every single tricky case we meet and inevitably we have to make what we hope is a sensible decision in difficult circumstances. Inevitably, on occasion, and with the benefit of hindsight, that decision may prove to be wrong - but surely not necessarily negligent.

Re: Exlap?

Hannah Wynne Richards — Sat, 07 Jan 2012 16:40:55 GMT

Malcolm Unfortuneately you're probably right about many others also being out of their depths but I'll stick with my assertion it wasn'ta post for someone returningto clinical work

I suppose one good thing about this case is that it clarifies the correct defensive course of action-conservative treatment It's just I'm left with an uneasy feeling "What if Dick is wrong, and this dog dies of peritonitis ?" I suppose I'll stick to a high fibre diet if the owners won't refer(though I won't go so far as cotton wool sandwiches-too much risk of a blockage ) and refer if possible Cowardly, I know, and some owners will be glad to be told surgery is contra-indicated as it saves them money Others don't mind paying, care deeply about their dog, and are understandably deeply unhappy about leaving glass inside it Before the DC hearing I would have operated, but now, if that is the dog that goes on to develop peritonitis, I'd rather the complaint to RCVS was about one of their own specialists-not about me

Wynne

Re: Exlap?

Hannah Wynne Richards — Sat, 07 Jan 2012 16:15:17 GMT

Kate I agree which is why in an earlier post on this thread I wrote "and the OOH provider (if on the register in the 1st place )"

Re: Exlap?

Judith Joyce — Sat, 07 Jan 2012 15:18:09 GMT

[quote user="Hannah Wynne Richards"]Malcolm With whom are you absolutely disagreeing?[/quote]

Sorry. With the suggestion that the disciplinary process should not interfere with matters of clinical "opinion".

I would urge everybody to read through this case in some detail before jumping to conclusions. The vet in question cocked up but he did nothing that many others in a similar position would have done. The criticism of him by others (in general practice) as part of the disciplinary process was intemperate and scientifically shaky in my opinion. It reflects badly on the disciplinary process that this one guy was made scape-goat and others in this thread have already started asking the questions that should have been put to the employer. My view is that the vet was well out of his depth on the night in question but I will be confident in predicting that he was no worse than many who will be on duty across the country this very evening. My understanding is that were it not for Dick's involvement, things could have been a lot worse.

Malcolm N