It shouldn’t happen to a vet

RE: It shouldn’t happen to a vet

Miriam Lodewyks — Mon, 05 Mar 2018 14:00:01 GMT

[quote user="T.H.vet"]"If this was your cat/dog, what would you do?" [/quote]

I sometimes struggle with this one when it's a chronic situation that's been ignored until things get totally out of hand, when you can't help but think "I just would never have let it go this far in the first place!".

RE: It shouldn’t happen to a vet

Anthony Todd — Sun, 04 Mar 2018 12:04:57 GMT

Not if you do this properly. I agree with Michael.

So the vet does advise and persuade which was all I was ever suggesting.

Sensibly, logically so.

RE: It shouldn’t happen to a vet

T.H.vet — Sat, 03 Mar 2018 14:53:32 GMT

I agree with Michael.All available options should be discussed taking into account the client's expectations,finance,animal's age and risk for surgery, and tailor the way you discuss these treatment options based of EBM(I know not all cases are clear cut but if relevant, I would supply clients with written material in laymans terms to help them understand the pros and cons of each treatment option and expected prognosis and recovery).

"If this was your cat/dog, what would you do?" If the client asks this question I would be honest with them and tell my opinon and the reason behind it adding at the end "However,this is entirely my personal opinion, you know *name of animal* best and whichever treatment/route you would like to chose, I would fully support your decision to help to make *name of animal* better".

Of course if there is a question of animal welfare due to poor QOL in an animal suffering from terminal cancer for example, we would have to be assertive that the animal needs to be euthanased so as not to prolong unnecessary suffering. Again, this is part of our code of conduct(https://www.rcvs.org.uk/setting-standards/advice-and-guidance/code-of-professional-conduct-for-veterinary-surgeons/supporting-guidance/euthanasia-of-animals/).

RE: It shouldn’t happen to a vet

Michael Woodhouse — Sat, 03 Mar 2018 12:07:04 GMT

[quote user="Anthony Todd"]"What would you advise?".....[/quote]

Not if you do this properly.

You don't tell the owner that their dog has ruptured it's cruciate ligament and can have rest and NSAIDS, lateral suture or send off for TPLO (et al), sit back and let them decide.

Assume a 12kg working cocker, I'd say something like:

Rest and NSAIDS for a month. Works better in smaller dogs and those happy to be in a cage. Cheapest option and many (smaller) dogs return to reasonable function. No point discussing cost of this alone as you're going to be doing this with one of the options below, anyway.

Lateral suture. We can do it here, cost ~£600, usually sound by suture removal and gradual return to work over the next few months. We've done quite a few and had many return back to work. IF it went wrong we are no worse off and could still go for option 3

Advanced, referral surgery. We have a good referral place and I'm not going to put words in his mouth so generally say it will be £2000+ but faster return to recovery and possibly better overall outcome.

The owner, in my experience will pick B most of the time, C if insured and A if broke. If it's a little, useless dog with no athletic capability then I'd steer towards A. The way you phrase things can guide the process but generally when given the options (properly) people make their own decision.

IF they asked me what I'd do, I'd pick B.......

RE: It shouldn’t happen to a vet

Anthony Todd — Sat, 03 Mar 2018 11:50:25 GMT

At risk of another turbo my point is, and always has been, that the only person with the knowledge and experience to make those decisions is the vet in front of the client.

Invariably, the client says "What would you advise?".....

RE: It shouldn’t happen to a vet

T.H.vet — Sat, 03 Mar 2018 10:48:32 GMT

If you read the annual reports of claims from VDS there were 21265 requests for advice in 2015. It is not clear whether this number represents a sum of simple advice requests and civil claims etc but 42.5% were RCVS/VCI complaints and 57% civil claims. Dogs were involved in the claims mostly(57%) followed by cats(14%) and horses(13%).

As noted in this report(https://www.thevds.co.uk/media/1444/vds-annual-review-2015.pdf), small animal vets can be caught out on pet passport inaccuracies,insurance claim inaccuracies as well as clinical mistakes.

Fortunately, I have never been sued by a client but you never know in your career when you may be unexpectedly caught out by unexpected circumstances.

Regarding the owner unable to make decisions - Isn't is the reason why we aim to give an informed consent by explaining what is expected to happen,prognosis,treatment options etc as best as we can to help the owners make this decision? This is part of our professional code of conduct too(https://www.rcvs.org.uk/setting-standards/advice-and-guidance/code-of-professional-conduct-for-veterinary-surgeons/supporting-guidance/communication-and-consent/)

If the owner is emotionally upset, I would sometimes advice that they do not need to rush their decision(unless it is an emergency that needs immediate medical attention) to speak and discuss with close relatives/family members before deciding which way they want to go.

RE: It shouldn’t happen to a vet

Anthony Todd — Sat, 03 Mar 2018 08:55:07 GMT

[quote user="T.H.vet"]I agree that giving the options to the owner and reiterating the possible complications,level of care provided are always recommended to prevent litigation these days. [/quote]

I know litigation is always mentioned these days but has it actually happened and what were the circumstances and outcome?

How can the average member of the public be expected to make an informed decision in a stressful emotional situation when they cannot possibly be expected to have the knowledge to make such a decision?

RE: It shouldn’t happen to a vet

T.H.vet — Fri, 02 Mar 2018 20:14:17 GMT

My first veterinary job at a private veterinary practice did not have any nearby referral centres so I used to do a range of surgeries fortunately with the help of more senior vets.

I remember seeing a labrador with ruptured splenic hemangiosarcoma causing hemoabdomen. We did not have donors at the time so performed 'autotransfusion' of the drained and filtered blood from the abdomen whilst also correcting dehydration and hypovolemia with crystalloids.

The labrador went through splenectomy,recovered well but was euthanised 3 months later due to metastatic lesions to the liver.

I agree that giving the options to the owner and reiterating the possible complications,level of care provided are always recommended to prevent litigation these days.

RE: It shouldn’t happen to a vet

Tim Browning — Sat, 24 Feb 2018 11:52:54 GMT

[quote user="Kay Varley"]

I would hugely recommend charity practice as a place to see it all and do it all. I did far more orthopaedics and weird and wonderful soft tissue surgery than I have ever done since in private practice (thanks Tim!).

[/quote]

Thanks Kay !

RE: It shouldn’t happen to a vet

David Catlow — Mon, 19 Feb 2018 22:20:34 GMT

[quote user="Kay Varley"]

[/quote]

yes charity practice clients generally don’t have referral as an option, so the vets get to do as much as they can do (Within scope of service!)

A great way to gain very broad experience

RE: It shouldn’t happen to a vet

David Catlow — Mon, 19 Feb 2018 22:17:27 GMT

[quote user="Gillian Mostyn"]

I just think we just have to accept that small animal vets in urban practices are no longer going to maintain omnicompetence, but instead we are moving toward the human model -whether we like it or not!

It's a shame, but it is mainly due to the change in public pressure/ knowledge/ litigation.

[/quote]

Public expectation and knowledge has certainly changed. The interweb and media

Historically, there were fewer opportunities for specialisation and career development, so the profession itself, not the public, has driven most of the changes and it’s generally a good thing, advancing standards across the board.

what we perhaps failed to realise as a profession was the consequential increased expectation of the public and changed reality for vets working in primary care practice who find it harder to see the caseload and develop advanced skills relatively quickly if they have to refer outside the practice

It is very dependent on the skill set of colleagues, culture, business model and support of the practice you work in.

RE: It shouldn’t happen to a vet

Kay Varley — Mon, 19 Feb 2018 22:05:17 GMT

RE: It shouldn’t happen to a vet

Richard Carter — Mon, 19 Feb 2018 14:30:06 GMT

Think we do need more assertiveness and a firm resistance to this 'client is always right' - no - we are the trained and experienced professionals - I will go out of my way to try help BUT if the prognosis is hopeless, funds limited, owner going on holiday etc etc then my professional opinion is the following ... Don't like it, practice down the road...

Complications happen - for the worst ones there is professional insurance. Not a reason to stop being a vet

RE: It shouldn’t happen to a vet

Tim Browning — Mon, 19 Feb 2018 14:10:21 GMT

[quote user="Julie Innes"]Ex lap there resulted in nephrectomy and ureterectomy, patial adrenalectomy, partial duodenectomy and (I think) the pancreas was removed/ partially removed too.[/quote]

Not quite as dramatic as the back legs and tail amputation on the other thread but getting there...I feel vets sometimes have a too great

can do attitude and need to develop a should do attitude more; but of course it's the owner's decision and they are often not the most disinterested animal's advocate.

RE: It shouldn’t happen to a vet

Julie Innes — Mon, 19 Feb 2018 13:38:04 GMT

WE had a similar case to Gillian's quite recently- pale dog, distended abdo, could see large mass on ultrasound, but I wasn't convinced it was spleen. Discussed options with owners- ex lap with us vs at referral centre. Dog was young and insured and they opted for referral. Ex lap there resulted in nephrectomy and ureterectomy, patial adrenalectomy, partial duodenectomy and (I think) the pancreas was removed/ partially removed too.

None of which we would have been confident to have done. Would most likely have euthanased on the table.

So good call to refer...although the dog deteriorated and was euthanased within a fortnight

Ultimately the owner's decision. It is the dreaded "Is there nothing else you can do?" Well, yes...

In my first jobs I had a go at pretty much everything. But the times have really changed, and I am far far more cautious now than I ever was. It's sad, but there you go. Not helped by a recent case, op with lots of potential complications, owner well warned, complications happened, owner attempting to sue us. Really not worth the hassle, and puts you off anything out of the ordinary

RE: It shouldn’t happen to a vet

Gillian Mostyn — Mon, 19 Feb 2018 07:10:06 GMT

I was convinced my dog was going to be a splenectomy, and had discussed poor survival rates etc. Unfortunately as it was a massive collapsed dog with a mahoosively distended abdo, palpation was impossible. In the end, an ultrasound scan showed it was a large bleeding mass in the caudal abdo and it was just euthanased.

I have also drawn and administered blood, and would happily do so again if necessary. But sending to the hospital would mean it would all happen a lot quicker ... It would take me time to get a donor dog etc.

Oh...and I would still do a splenectomy, pyo etc in a dog in first opinion practice....the issue was the near-to-death status of this dog, not the procedure itself. Caught quickly, I agree with Michael that it can be a straight forward op and the dog often goes home the same day. This dog was going to need significantly more than that! (As transpired, as it happens, when it wasn't a 'routine' splenectomy).

Lots of good points made above though. Food for thought. But I'm on my way to the airport for a week in Lanzarote so....signing out!

RE: It shouldn’t happen to a vet

Rob Loxley — Sun, 18 Feb 2018 23:34:19 GMT

[quote user="Gillian Mostyn"]Life was much much easier when that choice wasn't available, and certainly gave all staff more opportunity to do these ops. After all, the dog is dying...you can't make it worse and the owners appreciated you trying. Nowadays, if they later found out that 'better' care may have been available..[/quote]

Is the outcome from a referral option always better? I know where you're coming from but we risk de-skilling ourselves in general practice. Maybe I can refer the patella luxation to a Specialist, but I'm not sure the outcome would necessarily be clinically better. The pyo might get more 'intensive monitoring' in a referral hospital, but it'd be a sad day when general practice didn't feel it could take these cases on with successful outcomes. Hey, I could refer every bitch spay for someone to do a lap-spay...
I think the skills and achievements of general practice in providing the bulk of the nation's veterinary care, successfully and at affordable prices, with high levels of client satisfaction need celebrating more.
Maybe an answer is to skill-up general practice, push certificate level further qualification. There's no reason a general practice can't have the kit and ability to do a blood transfusion (or use the pet blood bank), and organise the necessary post-operative care (since we all have to still provide our patients 24/7 cover) for a splenectomy?

RE: It shouldn’t happen to a vet

Michael Woodhouse — Sun, 18 Feb 2018 23:16:18 GMT

[quote user="Gillian Mostyn"]but with no overnight supervision or blood transfusion in the near future[/quote]

I can collect and be administering blood before they could get to the nearest referral centre. Lots of people will lend me a Labrador if needed.

I've always been amazed how splenectomies bounce back after some blood and surgery. Might not even need to stay in. There is no way on earth I'd refer my dog. (yes I know the 6 month survival is piss poor)

RE: It shouldn’t happen to a vet

Clare Tapsfield-Wright — Sun, 18 Feb 2018 22:36:25 GMT

[quote user="robloxley"]

[quote user="Clare Tapsfield-Wright"]they have just increased the salaries of vets to aid recruitment and retention of vets. Big price rises ahead for clients? [/quote]

Is that good or bad?

[/quote] I think realistic prices for routine stuff like spays would be good , no loss leaders which demean the value of treatment overall

RE: It shouldn’t happen to a vet

rhmrcvs — Sun, 18 Feb 2018 22:32:42 GMT

Have heard so many excuses over the years for basically not wanting to provide the care as its a pain in the ar**. I was on call night before i was booked for a caesar ( on me not an animal ) young vet from a neighbouring practice called to ask if we were a hospital. They had admitted a dog with pneumothorax which needed " looking after " and " our nurses wont do ooh checks " i advises we not hospital but provide whatever care is required , if animal needs ( or o wishes, in this case dog stable but o wanted constant care ) can have constant but staff need to be paid for time and will need to be off following day if up all night. The vet seemed surprised when i asked if she had considered caring for her own patient ! The name of the building doesnt govern the actual care given. We are not doctors , the nhs and its often ridiculous systems are nothing to do with us. Our patients are pets or an income stream ( sometimes both ) to their owners. We should deal with a haemoabdomen , stabilise at v least, be able to fix a cats femur , etc etc As a profession be careful what we wish for , the joy of veterinary medicine and surgery is variety , we are not operating on someones child, father, granny etc. To me the thought of just doing basic stuff is mind numbing ....... no wonder younger generation dont enjoy it.

RE: It shouldn’t happen to a vet

Evelyn Barbour-Hill — Sun, 18 Feb 2018 22:27:53 GMT

[quote user="Gillian Mostyn"] (By overnight supervision, I mean more than just 2 checks!)[/quote]

Of course. I was thinking more of sitting with it nearly all the time throughout the night. (Are you sure it will get that at the hospital?).

[quote user="Gillian Mostyn"] The economics of running an OOH service, while maintaining a reasonable working week for the staff, really is far from simple.[/quote]

It always used to be. Though we didn't call it an "OOH service" then. And it always has been for me (we don't have a smirk emoticon, do we?)

RE: It shouldn’t happen to a vet

Gillian Mostyn — Sun, 18 Feb 2018 22:22:27 GMT

[quote user="Kay Varley"]Back to the picture at the start - I seem to remember in one of James Herriot's books he complained that as a new graduate there was a lot of unemployment amongst vets and salaries were very low....![/quote]

And it is well known that money, amongst other problems, brought on serious bouts of depression.

"Mr Herriot" was also well acquainted with depression. He entered the Glasgow veterinary school in 1933 without a single science qualification. He struggled for years to make ends meet and money worries brought on a bout of profound depression in the 1960s.

"I thought for a time he was going to be one of the suicide men," said his son. "Part of the problem was that he kept things bottled up. Until his dying day [10 years ago] there was a part of him we didn't really know."

Pasted from:

https://www.google.co.uk/amp/www.independent.co.uk/news/uk/this-britain/loneliness-depression-and-stress-it-shouldnt-happen-to-a-vet-318050.html%3famp

RE: It shouldn’t happen to a vet

Gillian Mostyn — Sun, 18 Feb 2018 22:15:27 GMT

[quote user="Evelyn Barbour-Hill"]the overnight supervision one is the clincher, isn't it? Well, my solution would be to provide overnight supervision. (Simples ).So maybe the unwillingness of recent graduates to do what they call "out of hours" is part of the problem?[/quote]

Not so simples. The economics of running an OOH service, while maintaining a reasonable working week for the staff, really is far from simple. (By overnight supervision, I mean more than just 2 checks!)

RE: It shouldn’t happen to a vet

Kay Varley — Sun, 18 Feb 2018 20:24:57 GMT

Back to the picture at the start - I seem to remember in one of James Herriot's books he complained that as a new graduate there was a lot of unemployment amongst vets and salaries were very low....!

RE: It shouldn’t happen to a vet

Christina Smith — Sun, 18 Feb 2018 20:14:10 GMT

The NHS is now sending 'simple lumps' back to the GPs. The overnight thing is difficult though. Anthropomorphism is rife.