Case studies on snakebite envenomation
Published in October 2019 issue of Vetboard Victoria's newsletter
The following case studies provide an opportunity for general reflection. Each case study is based on a complaint about an individual set of circumstances at a particular time. As veterinary knowledge and professional and community standards and expectations change over time, readers should not assume that the Vet Board would make the same decision when presented with a similar complaint.
With summer fast approaching, it seems timely to take a longer look at complaints involving the treatment of animals presenting with suspected snakebite.
Over the past 10 years, the Vet Board has received complaints about the treatment of snakebite in dogs, cats and horses on a regular basis, and each year at least one of these complaints has progressed to an informal hearing. This was the case in the two examples which we explore in more detail below.
These complaints highlight the importance of clearly communicating with clients and the need to rapidly diagnose snakebite and provide life-saving treatment. In each of these cases, anti-venom was not administered.
Following initial assessment, the Board conducted a preliminary investigation of each case, assessing the complainant’s information and the veterinary practitioner’s response. Both matters were referred to informal hearings to establish whether the veterinary practitioners’ clinical management of the animals may have been of a lesser standard than that which might reasonably expected of a veterinary practitioner by their peers and/or the public.
In the first case, an owner asked the veterinary practitioner to give the dog anti-venom because they had seen the dog fighting with a snake and suspected it had been bitten.
Examination confirmed that the dog’s symptoms were consistent with snakebite. During the consultation, discussions between vet and owner broke down. The vet administered cortisone and antibiotics and advised the owner to take the dog to an emergency centre for further treatment. However, the owner took the dog home, believing that the dog had received adequate treatment.
A short time later, the dog’s condition deteriorated rapidly, and the owner took the dog to another veterinary clinic, where anti-venom was administered. The dog’s condition did not improve, and he died later that day.
The informal hearing panel considered the allegation that, despite evidence from the owner and clinical examination results supporting a diagnosis of snakebite, the vet failed to administer anti-venom and/or treat for snake envenomation.
In this case the veterinary practitioner:
- admitted that they refused to administer anti-venom because they were unable to fully communicate their usual “standards of care” protocols to the dog’s owner
- told the Panel that the clinic had stocks of anti-venom which would have been appropriate to administer for bites from snakes in the local area
- had observed that the dog was unable to stand or walk, and accepted that the dog had been bitten by a snake
- acknowledged that they allowed the dog to leave the clinic without appropriate treatment (anti-venom) and without clear directions on the need for further veterinary care, and
- admitted they knew the owner would take the dog home rather than to the emergency centre.
The panel accepted that it was the vet’s normal practice to have a conversation with the client including prognosis, treatment options and potential complications - in accordance with good veterinary practice. However, the Panel expressed the view that in this urgent circumstance adherence to standard
protocols resulted in poor communication with the owner, to the dog’s detriment.
The panel held that it should have been apparent to the vet that the owner did not fully understand the seriousness of the dog’s condition. It was incumbent on the vet to tell the owner in clear and stark terms that it was likely the dog would die if it did not receive immediate emergency treatment. Further, the panel firmly expressed the view that cortisone and antibiotics were not appropriate or reasonable treatment for snake envenomation. The vet acknowledged that they had treated the dog both inappropriately and inadequately, and expressed considerable remorse for their actions.
Time was a crucial factor in this case. The dog did not receive potentially life-saving treatment due to the communication breakdown between the vet and the owner, contributed to by the inflexibility and inadequacy of the vet’s communications.
In the second case, the owner found a dead snake in their yard and suspected their two dogs had been bitten. After speaking with the vet over the phone, the owner drove both dogs to the veterinary clinic for urgent treatment.
The vet examined both dogs and commenced diagnostic tests for snake envenomation. Although one of the dogs clearly had symptoms of snake envenomation, the vet did not administer anti-venom to the dog. This was despite receiving at least two requests to do so from the dog’s owner. The dog’s condition quickly deteriorated, and he died a short time later.
The informal hearing panel considered the allegation that, that despite evidence from the owner and the dog’s symptoms supporting a diagnosis of snakebite, the vet failed to administer anti-venom and/or treat for snakebite envenomation.
In this case the vet was the only practitioner on duty at the clinic.
One of the two dogs was unable to walk and had been carried into the clinic. This was the dog examined first. Clinical examination showed he had a low temperature (37.3° – 37.4°), slow pupillary light reflexes and was unusually quiet. A creatine kinase (CK) blood test was within the normal range.
While the vet was performing a CK test on the second dog, the owner alerted them that the first dog’s condition had deteriorated markedly. The vet administered oxygen, but the dog died a short time later. The vet did not attempt to resuscitate the dog, believing that he would not have responded. In total, the dog had been at the clinic for approximately thirty minutes between presentation and death.
The veterinary practitioner agreed that:
- the owner had asked them to give this dog anti-venom on arrival but did not administer anti-venom because they had not yet made a definitive diagnosis and wanted to exclude other possible causes for the dog’s symptoms such as ingestion of poison bait
- the high cost of the anti-venom was a factor in their decision not to administer it
- they were unaware that the first dog had been presented to the clinic twice in the previous twelve months for snake envenomation and that anti-venom had been administered on both occasions
- they should have looked at the clinical notes or asked the owner for further information about the dog’s history but failed to do so on the night.
The panel decided that the information presented to this vet at the time clearly indicated that the first dog had almost certainly been bitten by a snake. The Panel noted that the dog’s symptoms were already well advanced when he was presented to the vet and this, together with the rapid decline in the dog’s condition, suggested the dog may have received a significant amount of venom when bitten. As such, there was a high probability that the dog would not have survived even if anti-venom had been administered.
The panel expressed the view that a more immediate and specific response should have been expected of the vet, based on the information available to them at the time and the owner’s specific requests for anti-venom to be administered.
Similar to the first case, the panel here considered that the veterinary practitioner had allowed their clinical diagnostic approach to divert their focus from the need for urgent and specific treatment for the most likely diagnosis – snake envenomation.
Given the likelihood of envenomation and the owner’s consent to administration of anti-venom, the panel’s view was that, even though the CK test result was in the normal range, it was unreasonable to delay time-critical treatment.
The panel noted that the vet was relatively inexperienced, working under difficult circumstances and had no other colleagues to consult with because they were the only practitioner on duty that night. It was accepted that this may have contributed to errors of judgement in what was an emergency situation.
Findings
The informal hearing panels found that in each of the above cases there had been unprofessional conduct by the veterinary practitioners, and the panels determined that the veterinary practitioners should be counselled.
WHAT IS COUNSELLING?
Counselling is one of the determinations that may be made by a hearing panel after a finding of unprofessional conduct.
It is a formal process during which a veterinary practitioner is informed how their conduct failed to meet the minimum required standard and how that standard might be met in the future.
A hearing panel may counsel in any way it sees fit. Counselling may be verbal or written; it may be given immediately or within 28 days of the determination.
Counselling is permanently recorded on a veterinary practitioner’s file and may be referred to in any future hearing or action taken by the Vet Board.
Reflections
Common themes in these complaints are the highly emotional nature of the consultations and the need to rapidly diagnose envenomation and provide life-saving treatment.
This places conflicting demands on a practitioner, who must communicate clearly with the client while providing urgent treatment to the animal.
At all times, veterinary practitioners should prioritise the welfare of the animal and be prepared to take command of the situation.
Management of snakebite cases is complex, and clear communications are essential to avoid misunderstanding. Clients in such cases often have to make time-critical decisions when highly stressed.
Emergency situations such as these can be intensely difficult for all involved. Clients may be very emotional and unable to take in information or fully comprehend the gravity of the situation.
People take time to process complex information, so it may assist to give the client pre-prepared material to read while the practitioner is performing diagnostics and administering first aid. This may help them make an informed decision about the care of their animal. As well as covering diagnosis, treatment and prognosis, such material could include an estimate of costs, the level of care which can be provided, availability of after-hours care, and referral options for intensive treatment and monitoring.
Practitioners may be cautious about proceeding with treatment because of the high cost of anti-venom, and the unpredictable outcome of treatment for snakebite. Clients who better understand the decision-making process faced by a practitioner are less likely to feel aggrieved at an adverse outcome.
On costs, vets should not withhold information about high cost treatments on the assumption that their client cannot pay for the treatment. Vets should provide estimates to clients at the outset of diagnostics and treatment, and regularly update them. Costs can rapidly escalate in cases which need intensive ongoing management.
Veterinary practitioners who practise in areas where snakebite is a common occurrence should have a very clear process for clinical management of cases, including record keeping. Stages in the process should include first aid, diagnostics, access to anti-venom and the ability to provide ongoing care to a patient. Alternatives to treatment (such as euthanasia) should be considered and discussed with the client.
Veterinary practitioners who are new to an area should make themselves aware of the possibility of snake envenomation, the types of snakes likely to be involved, clinical presentation and the process they should follow to diagnose and manage animals affected by snakebite. Second opinions should be considered where a diagnosis cannot be made or where an animal is not responding to treatment as expected. Again, an ongoing dialogue between the client and the practitioner responsible for the patient’s management is an essential part of this process.
Relevant guidelines and related reflections