college connection
LEARNING IN PRACTICE
Members of the veterinary profession have a responsibility to uphold standards to ensure the public has access to safe,
quality veterinary care. When those standards are compromised, the College responds. Every veterinarian can learn from
these situations and publishing the details of complaints received and resolved is intended to support that learning. The
example below is taken from an actual case and is offered as a self-reflection tool to improve practice across the province.
MEMBER GIVEN GUIDANCE ON MEDICAL RECORDS, STEROID USE
CASE SUMMARY
probable chronic renal disease.
The client’s dog had been a regular patient
and was seen for routine preventative
health care, anal sac issues, and itchy
skin. The member administered repeated
corticosteroid injections. With each injection,
the dog seemed to become more lethargic.
In January, the member saw the dog for itchy
skin and increasing lethargy. The member
radiographed her chest and determined the
dog was in early congestive heart failure. The
member administered a corticosteroid, DepoMedrol, and a long-acting injectable antibiotic
to address the itchy skin.
The client alleged the member failed to
discuss the side effects or the risks of
the steroids; failed to perform appropriate
tests when treating the dog with steroids;
misdiagnosed the dog with a serious heart
condition; and failed to make or keep proper
medical records.
Following this appointment, the client took
the dog for a second opinion. Veterinarian
A performed a physical examination, and
repeated radiographs which revealed
an enlarged liver, and mild enlargement
of the heart with a bronchiolar pattern
over the caudal, dorsal lung field, and
an absent cardiac waist, but no fluid was
seen. Blood was drawn for complete blood
count, chemistry panel, thyroid levels, and
a urinalysis was completed. Results were
validated at an external laboratory, and it was
determined multiple enzymes associated
with the liver were elevated, notably the
Alanine Transferase. This enzyme elevates as
liver cells are damaged/dying. Pre and post
prandial serum bile acids were also found
to be elevated, indicating the liver was not
working appropriately.
Veterinarian A began treatment with
antihistamines, S-AdenosylMethionine,
vitamins, prescription diets and medicated
shampoos. The dog was thought to have a
steroid induced hepatopathy (liver disease
resulting from chronic steroid use) so an
internal medicine specialist performed a
physical examination, abdominal ultrasound,
and assessment on the dog. The findings
were consistent with hepatopathy, enteropathy
of the duodenum and cecum, probable
chronic active pancreatic disease, and
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College Connection
CASE CONSIDERATIONS
The panel found it difficult to evaluate or
support the member’s treatment decisions as
the medical records lacked sufficient detail.
Medicating the dog orally was difficult, which
does complicate treatment. Additionally, the
member recommended a food elimination
trial, but the required time frame to determine
success was never achieved. Neither of
these factors warranted repeated, chronic
doses of dexamethasone and Depo-Medrol,
especially without educating the client on the
implications of repeated steroid use.
The panel found over three years, the dog
received eight injections of dexamethasone
either alone or with Depo-Medrol. There was
one note in the medical record that the pros/
cons of steroid injection were discussed
with the client. The panel did not believe
this discussion included the side effects of
steroids when used acutely or chronically,
only the difference between oral and
injectable steroids.
With regard to the specific drugs and doses
of dexamethasone and Depo-Medrol, the
panel felt it important to elaborate on their use
in this case. Depo-Medrol is a ‘long acting’
corticosteroid and the usual goal is to use
as much as required and as little as possible
for as short an amount of time as possible.
Most of the time, the dog was administered
20mg at each dose. The panel agreed this
dose was high, for the size of the dog, and
repeated too often for safe use, given what
appeared to be mild clinical signs.
Given the number of times and length of
time the dog received steroid injections or
oral tablets, it would have been appropriate
to recommend some form of monitoring of
internal organ function. However, there was
no documentation of any testing other than
Heartworm/Tick testing as being performed,
offered, or declined.
With regard to the member’s diagnosis of
early heart failure, the panel noted it may have
been prudent for the member to consider
recommending other diagnostics to support
a diagnosis which is difficult to make on
radiographic findings alone.
The panel was also of the opinion the
member’s medical records in this case failed
to meet the requirements set out by the
College with regard to record keeping.
CASE OUTCOMES
The Complaints Committee panel decided
the allegations did not warrant a discipline
hearing. The panel had concerns with the
member’s use of cortiscosteroids without
advising the client of potential side effects;
the use of the injectable antibiotic Convenia;
and the member’s failure to maintain
a comprehensive medical record. The
member agreed to participate in a Mutual
Acknowledgement and Undertaking to
improve performance in his practice.
Through participation in the undertaking,
the member established a protocol to
ensure clients are informed about diseases,
conditions or procedures. The undertaking
included participation by the member
and staff in the College’s medical records
workshop and a peer review of eight medical
records. As well, the membe r was mentored
on specific standard of care issues related to
the case and prepared a paper summarizing
learnings.