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 CONSENT, CHANGES TO RECORDS
CASE SUMMARY
A neutered greyhound who had been bitten by another dog was taken to the hospital. After the dog had been evaluated, the member discussed the findings of the examination and a treatment plan with the client. They discussed taking a radiograph of the dog’ s chest to rule out pneumothorax, performing blood work, as well as sedating the dog to explore the one cm tear in the skin overlying the right side of his chest, prior to suturing the wound closed. The client declined the more extensive work-up and repair, and decided to take the dog home and treat with Clavamox and Metacam that she had on hand.
Shortly after leaving the hospital, the client noticed her dog was salivating profusely, whining, and appeared to have a swollen tongue. The client returned to the hospital, where the member attended to the dog in the client’ s car. The client inquired about the sedation given to the dog. The member initially said the dog had not been sedated, but upon further discussion, it was reported that an injection of hydromorphone( an opioid) had been given. CASE CONSIDERATIONS
In consideration of this complaint, a panel reviewed the material provided.
The panel recognized that in an emergency trauma situation, it is not always possible to obtain informed consent for all treatments administered, including analgesics and sedation. Veterinarians are obligated to alleviate pain and suffering, and in the case of an emergency( such as a significant trauma), can use professional judgement in following the necessary steps to do so, without always requiring consultation with the patient’ s owner.
Although the member indicated that she felt that she was alleviating the dog’ s pain, the panel was not of the opinion that the
small puncture wound qualified as an acute trauma, requiring emergency treatment. Given the mild-moderate discomfort that the dog was experiencing, the member should have first discussed the treatment plan with the client, and obtained her consent for the administration of hydromorphone. Obtaining informed consent, and allowing owners to make decisions regarding the treatment of their pet is essential, in any non-life threatening situation.
The client indicated she was not informed the dog had been sedated, and that even upon her return, the member continued to deny that any sedation was administered. It was only upon further questioning that the member reported the administration of hydromorphone. The member said this was simply an oversight and miscommunication. She had administered the hydromorphone as a means of analgesia( pain relief), rather than as sedation. The committee accepted the member’ s explanation.
In reviewing the medical record, the panel noted the dog received a 0.05mg / kg dose of hydromorphone, which is half of the widely published dose of 0.1 mg / kg. Although published sources identify potential adverse effects of hydromorphone, such as respiratory depression and bradycardia, the panel was of the opinion that such side effects were highly unlikely to occur at such a low dose. The panel also considered the length of time between the administration of hydromorphone( which occurred immediately after arrival according to the medical record), and the client leaving an hour later. Again, multiple published sources identify that the peak effect of hydromorphone occurs approximately 10-30 min post administration. The panel agreed that although it would have been ideal for the client to have been made aware of the injection of hydromorphone, the risk of significant side effects was minimal, given the period of time between
administration and discharge from the hospital, as well as the low dose he received.
The panel noted the discharge summary that was received by the client’ s primary veterinary hospital did not contain information about examining the dog in the car when the client returned to the clinic. This entry was included in the copy of the medical record obtained by the College. There were also other minor discrepancies noted between the two copies, including a description of the dog as‘ anxious’ on initial presentation, as well as concerns regarding thrombocytopenia.
The panel understands that in an emergency environment, medical records may be sent off to the referring veterinarian before the attending veterinarian is aware and has a chance to complete the record. While the member is able to make changes to the medical records, the changes need to be added as an addendum. It is not permitted to record the changes into the medical record as if it were the original comments or observations. 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 advised of the panel’ s concerns.
The member was advised by the panel of concerns regarding obtaining informed consent prior to proceeding with clinical intervention, as well as entering any changes in the medical record as an addendum, rather than suggesting the changes were part of the original document.
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