Transport between practice and OOH clinic

RE: Transport between practice and OOH clinic

Martin Atkinson — Fri, 07 Jul 2017 09:23:21 GMT

[quote user="bevs2251"]Taking animals home is not covered by veterinary insurance in NSW if anything goes wrong. I certainly have done it, last century, for small dogs/cats but would never do it now. NSW too litigious. Is this legal or covered by insurance in the UK ??[/quote]I would suggest that the VDS would be more sympathetic in this case that your car insurers if you have not advised them you are using it to transport patients.

RE: Transport between practice and OOH clinic

bevs2251 — Fri, 07 Jul 2017 07:01:01 GMT

Taking animals home is not covered by veterinary insurance in NSW if anything goes wrong. I certainly have done it, last century, for small dogs/cats but would never do it now. NSW too litigious. Is this legal or covered by insurance in the UK ??

As a one person practice some years ago working 60 hour+ weeks, being able to pass on after hours calls to a referral centre was a blessed relief. No-one should expect small 1-2 man practices to shoulder the burden of after hours emergencies, or going back to check on animals several times a night, these days. A sure path to the "green dream" route, lack of adequate rest, the possibility of making a major mistake from tiredness, as well as crabbiness to the clients.

RE: Transport between practice and OOH clinic

bevs2251 — Fri, 07 Jul 2017 06:36:15 GMT

"Many brits seem to think driving 30 mins or more to an OOH veterinary clinic is beyond the pale." Haha - 30 minutes driving ?? Would hardly get you anywhere in Australia !! I remember staying somewhere in the midlands and the B&B owner saying she'd never been to London, it was too far away !! I said "but it's only a couple of hours down the motorway !" To us, a 3-4 hour drive is a doddle !!

As a NSW Aussie vet, our Veterinary Surgeons Board has advised us that if you are unable to manage a case appropriately (such as providing after hours care, lack of skill level, or lack of monitoring equipment etc) then IT MUST BE REFERRED to someone that can - either another local vet or emergency centre, or risk a complaint. Clients are advised with cases that look like they may need to stay in hospital that there is no overnight monitoring and they have the option of taking the animal to the emergency centre. True emergencies are generally referred straight over. Most vet hospitals do not provide overnight monitoring any more, and most never did anyway. Very few have accommodation attached for nurses or vets to stay in, unlike the UK. More after hours emergency clinics are being taken over by specialist centres so are true 24 hour facilities. More vets are less inclined to hang on to complicated cases and are happy to let them stay at the referral centre, unless the client decides to bring the animal back to the original vet.

No one wants to do after hours any more, especially the younger graduates. Very few vets here would transport cases to the referral centre as it would likely have to be in their own car (not many have a dedicated ambulance). It's a bit different in the country areas although some larger cities now have combined 24 hour emergency/referral centres (for small animals, at least).

RE: Transport between practice and OOH clinic

Bob Russell — Wed, 21 Jun 2017 12:17:02 GMT

It sounds a little as if you are daring him to complain to the RCVS!

Might be an interesting set of conversations!

If cost cutting has resulted in such low standards then perhaps it is the only justification for allowing unannounced practice inspections. I don't have much of a grumble with such inspections as long as they are carried out with competence!

RE: Transport between practice and OOH clinic

Martin Atkinson — Wed, 21 Jun 2017 11:50:51 GMT

[quote user="Clive Ansell"]

[quote user="Linda Filshie"]That is horrific, Clive. Have you spoken to ProfCon? [/quote]

The words time, waste, of and pointless spring to mind albeit arranged in a different order.

[/quote]The irony with the practice close to me is that he threatened to report me to the RVC for suggesting to a mutual client that his care may be sub-optimal. I encouraged him to do so as I had enough information on him from a sworn testimony from a previous employee for him to dig himself a very big hole. Needless to say I heard no more.

RE: Transport between practice and OOH clinic

Lucy Fleming — Wed, 21 Jun 2017 11:50:08 GMT

[quote user="Thomas Johnson"]I was obviously very upset at the time, and while less so am still upset this morning. As to what would have happened for overnight care if he had survived the procedure, I would have stayed at the practice until he was well enough to be transported and would probably then have taken him home with me overnight.[/quote]

What a sad outcome for you, the owners and the cat, especially after all your hard work that day.

The overnight care, though reveals the reality for many medium sized practices. Unless in a large busy hospital with the case load to provide dedicated overnight staff, you are left with a vet that has worked a full shift already, and often has to do the same the next day. We may do our best in that situation but I don't think any of us are at our best. I know that I find dealing with unwell inpatients overnight or on weekends (plus potentially juggling other emergencies) stressful, and I know my decision making suffers when I am tired. Moving an unwell animal is obviously less than ideal, but keeping overnight care in house is not a perfect solution either.

RE: Transport between practice and OOH clinic

Thomas Johnson — Wed, 21 Jun 2017 10:15:52 GMT

[quote user="Francisco Gomez"]

Woud have been wrong to transfer the patient (by the practice, not the owner, so it can be as well monitored as possible during transfer) to the OOH, and then, in the case of recovery, it could have been monitored by the OOH staff?

I'm not suggesting you did anything wrong, not at all. But I wonder, if you had to take him home with you after the second op. It would still be a transport, wouldn't it?

[/quote]

You're quite right, and if at midnight I had been about to get in the car with the cat and take it home I might have decided differently and taken it to Vets Now myself.

RE: Transport between practice and OOH clinic

Francisco Gomez — Wed, 21 Jun 2017 10:07:45 GMT

Kudos to you for working your a*** off to try find the best outcome for your patient Thomas.

[quote user="Thomas Johnson"]

I would have stayed at the practice until he was well enough to be transported and would probably then have taken him home with me overnight.

[/quote]

But with the issue of transport and taking into account that you do need to sleep too after a full working day, and possibly working the next day too.

I'm not suggesting you did anything wrong, not at all. But I wonder, if you had to take him home with you after the second op. It would still be a transport, wouldn't it?

RE: Transport between practice and OOH clinic

Thomas Johnson — Wed, 21 Jun 2017 09:59:23 GMT

The issue of what to do with an animal that was too ill to transfer to an out of hours practice came up last night. The patient was a 10 year old male neutered burmese cat with a 6 week history of diarrhoea. The cat gets very aggressive at the practice, a basic examination in the consulting room is possible, but after 5 minutes or any sort of restraint he turns into a raging ball of teeth and claws. After no response to symptomatic treatment he was sedated a couple of weeks ago for blood sampling, and on palpation under sedation a 2cm diameter mass was palpable in his mid-abdomen. Bloods showed a mild leukocytosis and FNAs of the mass came back as epithelial neoplasia.

He was sedated again yesterday, had an ultrasound that showed that the mass was intestinal, there was an enlarged lymph node nearby, but FNAs taken and examined in-house just showed a mixed population of lymphocytes and some red blood cells. We proceeded to GA and ex-lap, the mass was at the ileocaecocolic junction, I removed a section of bowel and performed an end-to-end anastomosis with a single layer of 3/0 Monocryl simple interrupted sutures, and biopsied the lymph node (clean instruments). Flushed everything and closed the abdomen. Half way through the procedure he had a cardiac arrest, atipamazole and adrenaline were given i/v and cardiac massage was performed and his heart was beating again, it had stopped for less than 2 minutes.

He was taken off i/v fluids and given subcut fluids after the procedure as I was worried that we wouldn't be able to handle him later, his recovery was a bit slow so I placed another i/v catheter and put him back on i/v fluids. He gradually improved over the afternoon and at 6pm when I was giving him a Comfortan injection he was sitting up and tried to climb up onto my shoulder. His owner came in at 6.30pm to take him to Vets Now, but when I went to take him off fluids and put him in his basket he was much flatter and his temperature had dropped. I discussed with his owner that I was worried that there was a problem with the repair of the bowel and that we needed to operate again, I discussed that the anaesthetic was a risk, he was more unwell than when he had the anaesthetic earlier in the day, and he had had a cardiac arrest under that anaesthetic, but if we didn't operate and he developed a peritonitis that was likely to be fatal. At no point did I consider that we should still try and transfer him or put off a decision about what to do next. He was anaesthetised and his abdomen opened again, there was a 3x6mm area on the antemesenteric surface of the colon along the edge of the anastomosis that was darker than the rest of the bowel and didn't bleed when pricked with a needle, I felt that this area was becoming necrotic and needed removal, but that it should be possible to remove this area and re-suture without cutting out the whole anastamosis. Unfortunately as I was about to start his heart rate dropped, he was given i/v adrenaline but it continue to drop, there was no response to further adrenaline injections and cardiac massage.

I was obviously very upset at the time, and while less so am still upset this morning. As to what would have happened for overnight care if he had survived the procedure, I would have stayed at the practice until he was well enough to be transported and would probably then have taken him home with me overnight.

RE: Transport between practice and OOH clinic

Bob Russell — Wed, 21 Jun 2017 09:40:36 GMT

If they smile, are nice and cheap then that seems to be enough for all too many!

We are seeing a number coming back once they find the actual cost exceeds ours! Low cost clinics around here don't seem to be that low cost in the end!

RE: Transport between practice and OOH clinic

David Mills — Tue, 20 Jun 2017 20:50:27 GMT

Continuously amazed by the psychology of these clients.

I always think if I was to be operated on, would I choose the cheapest possible option? Obviously a lot would, and evidently do.

RE: Transport between practice and OOH clinic

Clive Ansell — Tue, 20 Jun 2017 19:41:26 GMT

[quote user="Linda Filshie"]That is horrific, Clive. Have you spoken to ProfCon? [/quote]

The words time, waste, of and pointless spring to mind albeit arranged in a different order.

seriously: not directly, although I have given professional opinions for RCVS and court cases where things have gone wrong and the clients have made complaints.

I have little or no sympathy with most of these clients; cheap skate carpet baggers looking for a deal and everything on the cheap, and then bellyaching when it, inevitably, goes mammaries up.

RE: Transport between practice and OOH clinic

Clive Ansell — Tue, 20 Jun 2017 19:28:53 GMT

[quote user="Martin Atkinson"]Sounds like cheap practice not too far from us [/quote]

No, the ones (>1) I'm referring too are in the West Midlands. sadly/worryingly there are plenty of them around, and they are certainly not confined to West Drayton.

RE: Transport between practice and OOH clinic

Martin Atkinson — Tue, 20 Jun 2017 17:38:37 GMT

[quote user="Clive Ansell"]

Higher volume/throughput with less post op recovery monitoring.

Discharging sooner (one low cost clinic I locumed for took in 2 batches of ops at 0900, and 1300 because they didn't have sufficient kennel space). Operating towards the end of the working day and discharging too quickly (a bit like aiming to land towards the end of the runway - if it goes belly up, you're stuffed)

using a large number of different and often inexperienced staff, changing locums, not retaining good permanent staff etc. Often foreign new graduates put in to difficult, rushed and stressful work environment.

Asepsis, (or should that be sepsis?). I've witnessed multiple procedures with the same surgical kit, animals being prepped on the same table with a bitch spey going on - anaesthetic machine each end of the table, rushed and insufficient surgical prep. I've seen dentals being done at the same time as bitch speys in the same area, and even on the same table.

anaesthesia and pain relief - again lack of attention to detail, often don't weigh animals, and give the same standard doses to all cats etc,

The one I have worked in have all given a nsaid for pain relief, but often at subclinical dose - that way they can claim on their glossy fancy websites that "all ops get pain relief", but they forget to state it is often at a homeopathic dose. Often multiple animals from the same syringe - just squirt a bit in to each as it were.

use of antibiotics to cover for low clinical standards.

[/quote]Sounds like a cheap practice not too far from us except for the bits I crossed through, he tries to do it all himself which is probably even worse. Only add animals recovering on the floor in pools of blood because there was not enough kennel facilities with staff stepping over them and in-patients dying in unchecked kennels or baskets on tables because there's no time to examine them.

Yet if they survive the clients think he's wonderful because the end result is the same as if the job was done properly, its cheap and hes a charmer and bullshitter.

RE: Transport between practice and OOH clinic

Linda Filshie — Tue, 20 Jun 2017 14:58:35 GMT

That is horrific, Clive. Have you spoken to ProfCon?

RE: Transport between practice and OOH clinic

Clive Ansell — Tue, 20 Jun 2017 14:03:25 GMT

[quote user="robloxley"]

[quote user="Clive Ansell"]never crunched the numbers, but I suppose it needs putting in to context that the cheapo places do far more ops a day, and discharge patients sooner (I've come across bitch speys being discharged with an hour of the op)[/quote]

Do you think they just do more ops but same % of complications, or a higher complication rate? Is it rushing to do more ops or discharging them quicker that is the cause. Are there other factors at play - materials, asepsis, pain relief, surgeon experience etc? I ask because your experience with frequent complications from postop cases surprises me, and I'm sure there's things to be learnt from it?

[/quote]

Anecdotally of course, I would think some (not all) of the low cost clinics have a higher complication rate in relation to routine surgeries.

Reasons I would think are those you've already cited; sub optimal clinical standards and lack of attention to detail.

Higher volume/throughput with less post op recovery monitoring.

anaesthesia and pain relief - again lack of attention to detail, often don't weigh animals, and give the same standard doses to all cats etc,

use of antibiotics to cover for low clinical standards.

I wouldn't entrust the care of a dead dog to some of these places.

RE: Transport between practice and OOH clinic

Rob Loxley — Mon, 19 Jun 2017 19:40:29 GMT

RE: Transport between practice and OOH clinic

Neil Wheadon — Mon, 19 Jun 2017 19:37:20 GMT

[quote user="Malcolm Ness"]Where are the Grammar Police when you need them?[/quote]

Thanks Malcolm, laughing very loudly.

I could edit it to dogs, but will leave it alone!!

Neil

RE: Transport between practice and OOH clinic

Malcolm Ness — Mon, 19 Jun 2017 19:36:17 GMT

[quote user="Neil Wheadon"]I had 2 clients arrive within half an hour of each other. Both had been castrated that day,[/quote]

Where are the Grammar Police when you need them?

RE: Transport between practice and OOH clinic

Neil Wheadon — Mon, 19 Jun 2017 19:13:57 GMT

[quote user="Anthony Todd"]

How many of these referrals to 24hr care happen after discharge after a routine procedure or indeed of any nature?

Zero to one a year I'd guess.

[/quote]

In practically my last shift at an OOH clinic 18 months ago. I had 2 clients arrive within half an hour of each other. Both had been castrated that day, both at the same practice. In both cases the testicular skin was full of blood and the dogs were in a lot of pain. In my opinion the surgery was poor, looking at the wound.

Boy oh boy was it hard to stop them seeing each other as I tried to placate them. I even used 2 separate consult rooms so that they wouldn't cross.

My job as an OOH vet was to treat the animal and to 'not comment' on the reasons, common, yes and it was practice dependant I'm afraid. The fact a report went back to the practice should alert the principle.

Neil

RE: Transport between practice and OOH clinic

Clive Ansell — Mon, 19 Jun 2017 17:58:11 GMT

[quote user="Anthony Todd"]

How many of these referrals to 24hr care happen after discharge after a routine procedure or indeed of any nature?

Zero to one a year I'd guess.

[/quote]

Varies enormously from practice to practice.

I used to work on a fairly regular basis at 2 emergency OOH clinics. We would almost never, if ever, see routine surgery post op complications from traditional independent practices. Different story with the cheap jack sweat shops where we would see several most weeks, so much so with one particular clinic that they had an in place financial arrangement to cover the costs.

I've never crunched the numbers, but I suppose it needs putting in to context that the cheapo places do far more ops a day, and discharge patients sooner (I've come across bitch speys being discharged with an hour of the op)

[quote user="Anthony Todd"]If a seriously ill animal is presented then refer straight away unless you want to give 24hour care.[/quote]

But, if a patient is "seriously ill" it may well be in need of immediate treatment or analgesia prior to referral - no?

RE: Transport between practice and OOH clinic

Anthony Todd — Mon, 19 Jun 2017 14:25:41 GMT

Nobody has yet mentioned "evidence" or numbers.

How many of these referrals to 24hr care happen after discharge after a routine procedure or indeed of any nature?

Zero to one a year I'd guess.

Of course an animal presenting with a requirement for emergency care overnight is just referred immediately and how many of those are there??

Is it really worth making such a fuss and refusal or referral with all the aggro that follows the one bitch spay [or it could be one a week, so see above] which looks a bit pale after the op.??

If a seriously ill animal is presented then refer straight away unless you want to give 24hour care.

Bite the bullet, give up "Neighbours" for the very few [or a lot] post-op referrals you would have had to make.

Easier to take charge of the case than refer in lots of cases??

The loss of goodwill via "washing your hands" of YOUR patient should make the agro worth it.

PS Most if not all of our really heavy complaints didn't come from poor treatment but from referrals when they should have been given, at least, some treatment.

RE: Transport between practice and OOH clinic

Malcolm Ness — Mon, 19 Jun 2017 13:11:35 GMT

[quote user="Clive Ansell"]Therefore, I would ask; what about routine neuters in young healthy animals in practices that don't do their own OOH, given that there is always a possibility, however slim, of a complication requiring overnight hospitalisation?[/quote]

I have said before that I believe vets should be free to do any procedure without restriction PROVIDED there is genuine and appropriately informed client consent.

[quote user="Clive Ansell"] One of those suffered severe brain damage and paralysis, and died 12 months later. Scary, very scary. [/quote]

That is one of the reasons for my previously posted opinion.

RE: Transport between practice and OOH clinic

Malcolm Ness — Mon, 19 Jun 2017 13:03:36 GMT

[quote user="Martin Atkinson"]

[quote user="Malcolm Ness"]

[quote user="Martin Atkinson"] not wishing you or yours to be treated anywhere other than in an institution which provides 24 hr care[/quote]

........ but that isn't what I wrote.

[/quote] @Malcolm Ness: 'I would never consent to anaesthesia and surgery for me or my dog in a facility that did not provide 24 care'???

[/quote]

not all TREATMENT involves anaesthesia and surgery.

RE: Transport between practice and OOH clinic

Clive Ansell — Mon, 19 Jun 2017 12:06:20 GMT

[quote user="robloxley"]

[quote user="Malcolm Ness"]

[quote user="Clive Ansell"]Would you advocate that all routine ops be only carried out at 24 hour staffed sites?[/quote]

Gillian drew the comparison with what we would want for our own dog. I would never consent to anaesthesia and surgery for me or my dog in a facility that did not provide 24 care.

[/quote]

Any anaesthesia; any surgery?
Just patients that are staying in overnight following surgery or any routine surgery on any patient?

[/quote]

My question was in response to Micheal's statement that ANY procedure should only be carried out where onsite 24 hour care can be given. Therefore, I would ask; what about routine neuters in young healthy animals in practices that don't do their own OOH, given that there is always a possibility, however slim, of a complication requiring overnight hospitalisation?

I would not personally agree to a general anaesthetic (For me, not my dog) unless full on site 24 hour care were available. I know of 2 people that have had some sort of crisis while having routine surgery in a BUPA hospital, and had to be blue lighted to the local NHS for emergency care afterwards (Wonder who picks up the tab for that?). One of those suffered severe brain damage and paralysis, and died 12 months later. Scary, very scary.