Who "owns" the patient and its treatment?

RE: Who "owns" the patient and its treatment?

Sarah McGurk — Fri, 03 Nov 2017 11:22:49 GMT

I was usually delighted to be sent a plan with an animal. Very rarely would I change the plan unless

1) I felt to follow the plan would endanger the animal

2) Something further came to light that meant the plan had to change.

If either of those things happened, I would work through things as tactfully as I could. I would explain my thinking in detail to the client, then would write a very detailed history to send to the daytime vet including an explanation of what I had told the client and why. Sometimes I would also phone to discuss complicated cases that were on their way back.

I always hoped that the practices would offer me the same courtesy and in general, I think we had quite a good rapport. Much easier if you are part of a regular team of course. On occasion, if something was very complex, I would take the patient back to its practice and explain face-to-face. My feeling was that we were part of a team with the practices who used our services and I hope some of the vets I worked with felt the same.

RE: Who "owns" the patient and its treatment?

Bob Russell — Fri, 03 Nov 2017 09:53:26 GMT

We will routinely try to send notes across to a practice covering OOH where I think there may be a problem. Other cases I will make sure the owners know what has been given (ed antibiotics/NSAI) and/or advise them to take medication with them if there is an issue.

I will also give my work mobile number on occasions so I can either see a patient or coordinate treatment if I don't.

It is only rarely that I am disturbed!

Sometimes things happen that are unexpected.

I don't like completely relinquishing responsibility out of hours but do like to control it for my sanity.

RE: Who "owns" the patient and its treatment?

Alistair Graham-Evans — Thu, 02 Nov 2017 23:53:00 GMT

Having been a locum, first opinion vet, manager and worked in an emergency centre ( jack of all trades and master of none ) I am of the opinion that communication is the key.

When referring a case for OOH cover we will usually phone and talk to the vet on call, and explain what has been done, our concerns and if it just needs babysitting. Sometimes we will say it's fine for the OOH vet to phone at any time to discuss decisions that need to be made. If we have a case that may deteriorate we print notes to give clients so the OOH vet has some history if things go bad.

I have issues with OOH centres that refuse to just do essentials overnight and over-monitor and get carried away with scans, lab work etc despite being told owner has financial constraints - this can lead to owner stress and unnecessary euthanasia ( eg are blood gases really needed for an acute simple fracture?) I also have a problem with OOH centres that do a huge investigation beyond the remit of the emergency - that is what specialist referrals are for.

Vets who can't do basic emergency surgery should not be working at OOH centres unless being supervised by a more experienced colleague. Also I fail to see what is wrong with delaying surgery for a gastric FB if no evidence of peritonitis. A gastic torsion surgery may take an hour for the actual operation but far more time is taken in the post-op care and monitoring when a good nursing team is essential - certainly more than 1 nurse!!!

RE: Who "owns" the patient and its treatment?

Robin Grimmer — Thu, 02 Nov 2017 21:25:35 GMT

DM: "His example wasn't that he was dealing with the dead and dying for 15 hours, but people coming down - I very much doubt he was chocka full of dire emergenices, it would have been the usual procession of ears and cystitis."

With respect, you weren't there, so you don't know. It was perfectly acceptable to leave a stable, non-obstructed gastric FB until there was time to do it - or perhaps I should have left the GDVs to die? It's called triage.

Also you say an open pyo should be left and returned to the user practice - OK maybe on a weekday but not acceptable to leave all weekend.

RE: Who "owns" the patient and its treatment?

Bibs — Thu, 02 Nov 2017 21:25:02 GMT

[quote user="David Mills"]

[quote user="Elizabeth Billimore"] If people are somehow offended by you doing what you know is right and noting down your justification, then that is a shame. [/quote]

If only it were so simple. One vet's right is another's wrong. It's not the OOH vet's place to decide on chronic treatment plans etc. but rather to view yourself as a locum, nothing more.

[/quote]

I've been a locum, and that's just being a vet in different locations. How does it change your decisions any more than seeing a case in a permanent job when your colleague saw it last time? Also dispensing antibiotics after an op you did isn't chronic treatment.

As an OOH vet I would not decide on chronic treatment plans but I would not ignore something that I think needs done. When an animal is under my care for 15 hours and I think it needs a test that will make a difference to the outcome overnight then I'll do it. If I didn't then several dogs I can think of would be dead by now.

OOH work is different to daytime. I manged to do 5 GDVs in 1 year as an OOH vet and one in the previous 10 years. I know you still get GDVs during the day but it took working OOH before I could say I was good/confident doing them. There are other things too such as trach tube placement that I would have been very nervous of before, but now im comfortable doing it. OOH work does make you good/better at certain things that years of day work won't. This is all in my experience of course.

RE: Who "owns" the patient and its treatment?

Robin Grimmer — Thu, 02 Nov 2017 20:42:37 GMT

[quote user="David Mills"]

[quote user="Robin Grimmer"]One possible solution would be to clone Mr Mills as he is so efficient.[/quote]

Jealousy is a very ugly emotion, old fruit.

[/quote]

Not jealousy, sarcasm dear boy.

RE: Who "owns" the patient and its treatment?

J G Wray — Thu, 02 Nov 2017 19:04:02 GMT

[quote user="Clive Ansell"]Nah, I just a lowly locum and know FA² about anything managerial. Did work briefly in management though, albeit long ago and it was not veterinary, and therefore doesn't count I guess.[/quote]

Nearly missed this piece of humility

Come come not "lowly". Limited knowledge of modern veterinary managerial stuff inevitable as a locum for so long. No leadership stuff either if you choose locum work.

I don't fancy being a locum. I don't venture opinions on how locums should function. This is occasionally forgotten by some.

I do think "Get off my land" though, when locums apparently see things with clarity, because life is more nuanced than at first glance. I also think locums are a bit "other", but that's their choice.

RE: Who "owns" the patient and its treatment?

David Mills — Thu, 02 Nov 2017 18:51:09 GMT

[quote user="Robin Grimmer"]One possible solution would be to clone Mr Mills as he is so efficient.[/quote]

Jealousy is a very ugly emotion, old fruit.

RE: Who "owns" the patient and its treatment?

David Mills — Thu, 02 Nov 2017 18:48:58 GMT

[quote user="Elizabeth Billimore"] If people are somehow offended by you doing what you know is right and noting down your justification, then that is a shame. [/quote]

If only it were so simple. One vet's right is another's wrong. It's not the OOH vet's place to decide on chronic treatment plans etc. but rather to view yourself as a locum, nothing more.

RE: Who "owns" the patient and its treatment?

David Mills — Thu, 02 Nov 2017 18:47:19 GMT

[quote user="mariette asselbergs"]But a lot of the work is quite particular for OOH situations.[/quote]

It really isn't.

This is cognitive bias in all its glory. You probably see more of these things as a percentage of your work (as you should), but they are not more common in OOH centres in terms of absolute numbers compared to say a big hospital.

[quote user="mariette asselbergs"]stabilising a FB obstructed animal for 15 hours while dealing with the more urgent case[/quote]

His example wasn't that he was dealing with the dead and dying for 15 hours, but people coming down - I very much doubt he was chocka full of dire emergenices, it would have been the usual procession of ears and cystitis.

[quote user="mariette asselbergs"]The examiner and marker seemed to suggest that we should influence the user practices to get them to do the "right" thing. [/quote]

I'm glad you see the preposterousness of this mindset, but unfortunately there is developing a somewhat ivory tower mindset in some OOH centres and their judgements of daytime practice, but akin to the university/first opinion kind of vibe. A lot of vets working in these centres seem to believe the marketing schmuck that hints at OOH centres being staffed by emergency specialists. I've heard tales of vets having to talk owners down from the ceiling when these vets have told them they will definitely need referral for their cat's fractured femur (it turns out the OOH vet had never even fixed one or seen one fixed in first opinion).

Likewise, it's about staying within the job description. If an animal is sent for babysitting don't start running up £100s in bloods overnight because it's "best practice", and don't paint the daytime vets into a corner with treatment or prognosis when you don't know. Don't fish for a diagnosis if you don't need to. Only operate when it is a true emergency (so leave the bright open pyo), and don't touch the orthopaedics apart from the open fractures.

I get the desire to do something, but in most cases it isn't your place. That's the bargain you strike when you work OOH, so please don't try and be a supervet hero. You get paid very well to do it, but the limits need respecting.

Quite simple, really.

RE: Who "owns" the patient and its treatment?

Neil Wheadon — Thu, 02 Nov 2017 12:48:38 GMT

[quote user="Elizabeth Billimore"]The practice I work for take patient transfers for OOH care. We don't often get plans sent to us and it's not unusual to slightly change tack on what we're treating.[/quote]

Martin Bryce at Emersons Green Vets won Pet Plan practice of the year 6 years ago and of the member practices we looked after in Bristol, he was very good at bridging that gap between daytime cover and OOH care. He would E Mail notes across for potential cases and bring some patients down personally to talk to the OOH vet on shift.

Therein lies the solution doesn't it, communication.

If you use an OOH service, things run smoother if you 'think of the other man/women' . Send that history, phone them up, maybe even work a week there (often looking for locums, so you'll get paid)

it will change your outlook on a service that is making 50% of the professions wellbeing a little better.

Neil

RE: Who "owns" the patient and its treatment?

Bibs — Thu, 02 Nov 2017 10:16:34 GMT

Interesting thread. I don't see why you can't do what you think is correct as long as you have justification and record your reasons. The post op antibiotics issue is a good example. I think I would appreciate an up to date vet sending me that kind of information and I would soak it up. I don't feel possessive about cases as long as I don't feel something has been done badly/carelessly. Maybe not everyone feels the same. If people are somehow offended by you doing what you know is right and noting down your justification, then that is a shame.

The practice I work for take patient transfers for OOH care. We don't often get plans sent to us and it's not unusual to slightly change tack on what we're treating. I think it's just two heads are better than one. Also often the day practice will see a very sick animal at the end of the day and ship it to us without having a lot of time to investigate. I have seen more than one unwell dog sent to us with an undiagnosed haemoabdmen. I pick these up because I love fast scanning anything very unwell. We also recently had a atypical Addison's case that wasn't diagnosed until the night vet thought the working diagnosis didn't quite fit, and maybe they should check a basal cortisol. The owner and the day vets were really happy that we had picked that up - it felt like team work.

I think a vet to vet chat is always a good move if it's not something straight forward. I think we should also try not to assume the worst of our colleagues. Usually they are trying their best in whatever situation they are dealing with.

RE: Who "owns" the patient and its treatment?

Julie Innes — Wed, 01 Nov 2017 22:42:08 GMT

I've no answers, Marie, but I wish you and your team were doing my OOH!

RE: Who "owns" the patient and its treatment?

mariette asselbergs — Wed, 01 Nov 2017 20:02:59 GMT

I knew there would be some firm opinions on this topic!

I am lucky to work in a small team where all of us are experienced, probably on average 20 plus years. All our nurses are also at least 10 years experienced, and their contribution is crucial. After a diagnosis and a treatment plan, actually monitoring and nursing the patient is life saving in seriously ill animals.

It is true that some of the work is the same as daytime work except being out of hours. But a lot of the work is quite particular for OOH situations. GDVs and unplanned caesarians are rare in the daytime, and RTAs seem to be increased at night and weekends when dog fights/bites also seem to be more frequent than I see in day practice when locuming. Foreign body obstructions always seem to end up with us by the time they need to be operated on, as do a lot of blocked cats.

And thanks for understanding from ex-OOH vets about the time consuming part of transfers of patients on drips or still needing a work up. There can be quiet evenings but the Friday is rarely the one!

As for management: it is managing for the unpredictable and unexpected, and stabilising a FB obstructed animal for 15 hours while dealing with the more urgent cases seems to me to be exactly that (The art of triage....)

Of course it is true that we are no specialists, but we are experienced in all the acute life threatening cases which most vets in daypractice without OOH only see every now and then (nowadays).

And of course the changing of a diagnosis (e.g. from HGE to pyo, from chronic cystitis to pyo, or from unblocked cat with catheter in for the weekend to cat with bladder full of stones) will never lead to criticism of the user-practice! Diagnosis can develop and change over time.

When I did my certificate exam, I was critisised (and marked down) for discharging a dog with a course of amoxyclav after clean-contaminated abdominal surgery with peri-operative intravenous antibiotics. I had given the post op course of antibiotics because I knew the user-practice was not happy with only peri-op iv antibiotics. But I was told that I should never let my treatment decisions be influenced by what others do (if they are "wrong").

The examiner and marker seemed to suggest that we should influence the user practices to get them to do the "right" thing. This seemed a bit preposterous to me, but are there practices out there who do have regular or shared CPDs with their OOH provider to discuss things like antibiotics use or type of analgesia post op? Or best evidence protocols for standard cases like pancreatitis, HGE, blocked cats, seizures, cat bite abscesses etc.

RE: Who "owns" the patient and its treatment?

Clive Ansell — Wed, 01 Nov 2017 18:42:09 GMT

[quote user="Robin Grimmer"]One possible solution would be to clone Mr Mills as he is so efficient.[/quote]

I've never considered it, but is it possible to clone a clone? (Not suggesting DM is a clone at all)

RE: Who "owns" the patient and its treatment?

Clive Ansell — Wed, 01 Nov 2017 18:39:11 GMT

[quote user="Neil Wheadon"]

We're really selling this job aren't we Clive?

[/quote]

We probably need to, we will all be snookered without functioning OOH clinics. I for one won't go back to working on call.

[quote user="Neil Wheadon"]Good job we don't understand management [/quote]

Nah, I just a lowly locum and know FA² about anything managerial. Did work briefly in management though, albeit long ago and it was not veterinary, and therefore doesn't count I guess.

RE: Who "owns" the patient and its treatment?

Thomas Johnson — Wed, 01 Nov 2017 16:09:52 GMT

[quote user="Bob Russell"]

There may be an obvious misdiagnosis but this is where professional consideration comes into play. The original practitioner should never be denigrated. The owner may not have given the same information, the clinical situation may have altered or the vet just went down the wrong path.

I will never comment negatively on a colleague to a client. I do not expect others to do so about me.

[/quote]

Absolutely agree, and it works the other way as well, an animal that has presented out of hours may be transferred to the member practice for further treatment in the morning, sometimes the information initially available will have pushed the out of hours vet in one direction, but new information, either from the owner or from further investigations may revise the probable diagnosis. This doesn't mean that the out of hours vet has done anything wrong, and the vet who has taken on the case shouldn't imply that to the owners.

Occasionally we all make mistakes and get something wrong, and there are usually ways of changing the approach without making the clients unhappy about the initial treatment. Obviously if the same vet is regularly getting diagnoses wrong or treating things inappropriately then some careful thought is needed about what to do.

RE: Who "owns" the patient and its treatment?

Malcolm Ness — Wed, 01 Nov 2017 15:59:54 GMT

[quote user="Neil Wheadon"]I really can't see how that would work Malcolm[/quote]

I think you are right, but then it doesn't have to "work" in a way that you or I would recognise. It is a political solution so in essence all that has to happen is for it to appear to change, ideally with something of a fanfare then everyone will be distracted and start talking about the next problem - even if the next problem is nothing more than the inevitable offspring of the last one.

RE: Who "owns" the patient and its treatment?

vs0u — Wed, 01 Nov 2017 15:54:41 GMT

[quote user="Robin Grimmer"]One possible solution would be to clone Mr Mills as he is so efficient.[/quote]

50-90 animals per day according to this article

http://www.telegraph.co.uk/sponsored/lifestyle/rspca-inspiring-animals/11931358/rspca-vet-video.html

http://www.telegraph.co.uk/sponsored/lifestyle/rspca-inspiring-animals/11899481/rspca-staff-story-david-mills.html

Never would have guessed he's a northener from his posts!

RE: Who "owns" the patient and its treatment?

Robin Grimmer — Wed, 01 Nov 2017 15:42:30 GMT

I think the bubble will burst with OOH work particularly post Brexit as propped up by EU workers.

One possible solution would be to clone Mr Mills as he is so efficient.

RE: Who "owns" the patient and its treatment?

Clive Ansell — Wed, 01 Nov 2017 15:05:57 GMT

[quote user="Edward Jones"]I've heard 'stories' of a particular OOH clinic being regularly staffed by vets who couldn't do a bitch spay. No idea if this was true, but I'd say this was totally insufficient if so. And not necessarily entirely the vet's fault.[/quote]

Well, who's fault is it then, Dennis Compton's?

Again, a veterinary surgeon who cannot carry out a planned elective procedure such as a bitch spay, is not ideally placed to have to carry out emergency abdominal surgery, often having to make a decision quickly, and often in a very sick, unstable and sometimes critical patient.

Such a veterinary surgeon should not accept the position.

The problem is not unique to OOH clinics either. I have more than once been asked at short notice to step in and take over from another locum that has been placed in a sole charge position and cannot cope. The most recent was a foreign new grad, who spoke broken English, in a sole charge position at a charity centre, and she had never spayed a cat! (She had never induced I/v anaesthesia, placed an ET tube, or placed an I/v cannula either).

RE: Who "owns" the patient and its treatment?

Neil Wheadon — Wed, 01 Nov 2017 14:56:37 GMT

[quote user="Clive Ansell"]Staff OOH clinics is notoriously difficult; able and willing experienced vets to pull off 15 hour shifts including sometimes having to deal with PDSA BS are thin on the ground.[/quote]

We're really selling this job aren't we Clive?

Good job we don't understand management

Neil

RE: Who "owns" the patient and its treatment?

Clive Ansell — Wed, 01 Nov 2017 14:51:05 GMT

[quote user="Edward Jones"]Whilst I agree that in the specific example of the urethrostomy the delay isn't particularly critical, but in general this is a failure of management. [/quote]

In part, possibly.

Staff OOH clinics is notoriously difficult; able and willing experienced vets to pull off 15 hour shifts including sometimes having to deal with PDSA BS are thin on the ground. Although it is easy to point the finger, management have a hard job to recruit suitable staff, and sometimes as long as they are MRCVS, they'll do.

Equally, responsibility has to lie with the veterinary surgeon who accepts a sole charge position in an OOH clinic when they don't have the necessary skills and experience to cope.

RE: Who "owns" the patient and its treatment?

Neil Wheadon — Wed, 01 Nov 2017 12:24:08 GMT

[quote user="Malcolm Ness"]One politically attractive possibility is to "extend the competency" of non-veterinary professionals. For example, train up some VNs in the new (so new that it doesn't exist yet!!) Diploma in Paraprofessional ECC.[/quote]

I really can't see how that would work Malcolm

OOH is not all about caesarians, blocked cats and GDV's, it's multilayered. In lots of cases you need to be a vet and very experienced. Mariette eluded to this in posing the question. A large number of cases are chronic conditions or recent cases that suddenly take a turn for the worse (or the owner is concerned) As the clinician presented with the case and are faced with a case with no history aside from what the owner can tell you, a list of medication that you don't know and no access to the computer systems where the history lies (this is why I print out histories for clients, if I suspect they may need OOH follow up) How can a trained up nurse cope with that?

OOH clinics have a frightening high churn rate and as a profession we are becoming far to reliant on these wonderful vets that are willing to work 15 hour shifts in light of an increasing amount of evidence that it's very bad for you long term to work nights in the patterns that OOH clinics are running (morbidity and mortality)

Neil

RE: Who "owns" the patient and its treatment?

Malcolm Ness — Wed, 01 Nov 2017 12:11:21 GMT

[quote user="Neil Wheadon"]it's a time bomb in my opinion[/quote]

No, it is a political challenge which, regrettably, will be met with a political solution.

For example, if there aren't enough vets working in UK - I disagree with that assertion and I have written on the subject, but the prevailing wisdom is that there are not enough vets - and if that is the premise, then we need to find other ways of doing what vets do. We can suck in economic migrants and that might mitigate the situation; we can train more vets and that will be an attractive option for as long as there is money to be made (or funds to be secured) for training more vets. But if all that isn't enough then our dear politicians have got to start "thinking outside the box" and that is where we are getting to just now. One politically attractive possibility is to "extend the competency" of non-veterinary professionals. For example, train up some VNs in the new (so new that it doesn't exist yet!!) Diploma in Paraprofessional ECC. There are already loads of nurses and given the possibility of them earning more and doing a new and exciting job, all those VNs who left their profession in disgust will be drawn back. Another option is to withdraw the duty to provide 24/7 cover - that will allow the appearance of multiple part-time/some-time/occasional veterinary services run as a "funded hobby" by those who can afford to and that could lead to the disintegration of most of the SA veterinary industry in this country. Problem solved!

I, for one, would welcome the explosion of the "time-bomb" of which you speak - while it will be messy in the short term it holds the possibility of rebuilding a veterinary work place that works for everyone - vets, nurses, employers, employees, clients and patients.