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, LYME DISEASE
CASE SUMMARY
The member examined a male, neutered, Retriever-cross dog who was lethargic and not eating well. The member suggested the dog had gotten into something. No diagnostic tests were performed and no treatment was initiated. Four days later, the dog was returned to the member. The dog now appeared to be in pain, had trouble walking, was not eating well and was vomiting. After performing blood work, the member dispensed Metacam, a non-steroidal anti-inflammatory, and doxycycline, an antibiotic, for suspected Lyme disease.
Two days later, the dog returned to the clinic a third time as he was not improving, not eating better, and not drinking much. At this time, Advantage Multi was dispensed and the dog was signed up for a“ wellness” plan. In four days, the dog returned to the clinic for radiographs. The member indicated the dog’ s intestines were full but there was no need to change the treatment plan.
The client called the next day and made another appointment for the following day after reporting the dog was no better, had passed a black stool, and continued to pant. The client requested an earlier appointment that morning but the dog died before the afternoon appointment. A post mortem was performed and a rare form of leukemia was diagnosed.
CASE CONSIDERATIONS
In consideration of this complaint, a panel reviewed the material provided.
The panel was concerned the clients did not appear to have understood the member’ s suspicion of Lyme disease. While the member submitted that he / she did explain Lyme disease to the clients, there was no record of a discussion offering additional diagnostic testing such as a quantitative C6 test or urinalysis to assess for proteinuria.
The complete blood count appeared to have been performed twice on the same sample; however there was no record of interpretation or concern for the leukocytosis( high white blood cell count) or severe thrombocytopenia( lack of platelets) on the printed report, or a notation that a blood smear was performed to validate the findings. The clients felt the dog had been on a program to protect him from ticks, but there was no note of a tick management discussion, review of access to ticks or preventative products used.
The panel was concerned the member failed to look more deeply into the dog’ s illness despite the client’ s request. While some cases of Lyme disease can start as vague malaise, the dog continued to deteriorate despite treatment, and there was no indication the client declined services. The panel was of the impression the client respected the member’ s recommendations and had confidence that he / she was doing all that was required.
The panel noted a lack of completeness in the medical records. The panel was unable to evaluate the member’ s consideration or communication of options, rule outs, assessments and plans.
The panel was also concerned the member dispensed Apo-Meloxicam knowing the dog was not eating or drinking, was vomiting and there was evidence of anemia and thrombocytopenia.
The panel also examined the radiographs. Although they were not properly identified, the panel did not suspect they did not belong to the dog. The panel hopes the lack of identification markings on the radiograph, which is required to identify the patient, the clinic, the date and the view, was an isolated error.
The panel considered that failure to offer a second opinion is not necessarily an
omission; however it might have been a valid consideration in a clinic with multiple veterinarians to discuss a difficult case.
The panel further noted it was unfortunate the clinic staff failed to accommodate the request for an earlier appointment when the dog’ s condition was critical. While this would not have changed the outcome, it is important that veterinary staff not expect clients to be able to indicate when a patient is“ critical”. Because the dog had been in poor condition for so long, it would have been difficult for the clients to evaluate deterioration.
The panel expressed its condolences to the clients on their loss. The panel was of the opinion the clients respected the member’ s judgement. While they are not holding the member liable for the dog’ s death, as it was ultimately determined he had a rare cancer with a grave prognosis, they are holding the member responsible for the poor quality of his last 13 days.
CASE OUTCOMES
The Complaints Committee panel decided that the nature of the allegations made against the member did not warrant a discipline hearing and therefore directed that this matter not be referred to the Discipline Committee. However, the member was invited and agreed to participate in an undertaking to address the panel’ s concerns.
Through participation in the undertaking, the member completed two separate written studies addressing Lyme disease in dogs and secondly the use of non-steroidal inflammatory drugs in dogs. The member’ s records were reviewed by a peer reviewer and a medical records workshop was provided to the member and the clinic staff.
6 / College Connection