Case study on ownership and communication re clinical management
Published in the October 2011 issue of Vetboard Victoria's newsletter
The following case study provides an opportunity for general reflection. The 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.
Background
A dog was presented to a veterinary clinic by a person caring for the dog while the owner was away. The dog had been involved in a dog fight during the day and was presented in a state of collapse with extensive wounds to both forelimbs. Treatment was instigated to stabilise the dog’s condition. The admitting veterinarian was of the opinion that they would be unable to save the legs and offered referral or euthanasia. After the carer declined both the options of referral and euthanasia, the veterinarian agreed to provide veterinary treatment to stabilise the dog until the owner could be contacted. The dog survived the night and was removed from the clinic, and placed into the care of another clinic the following day at his owner’s request. The dog’s owner and carer allege that the dog was not treated with adequate care by the original veterinary practitioners because the wounds were not bandaged and the dog’s bedding was blood stained.
Veterinary Care
The Board considered that the veterinary care provided was satisfactory and that which would be expected of a veterinary practitioner. The dog presented in a collapsed state with severe and extensive wounds to both forelimbs. Clinical examination revealed pale mucous membranes, rapid heart rate, slow capillary refill time, cold extremities; hypotension and hypothermia. The dog was immediately and appropriately diagnosed with hypovolaemic shock. The dog’s wounds were dry with no active bleeding or discharge.
Treatment, including intravenous fluids at shock rates, active warming, analgesia, and antibiotic cover, was immediately administered to the dog to stabilise his condition. The practitioners were of the opinion that they could not save the dog’s legs and thus they offered the alternatives of referral or euthanasia. The dog’s owner could not be contacted and the option of referral was refused, so the dog was kept at the clinic overnight on supportive therapy. The dog’s response to treatment was closely monitored by staff until they left for the evening (approximately 3am). The Board considered that the treatment administered to the dog was both necessary and appropriate for his condition. Without such treatment, it is unlikely that the dog would have survived the night. Emergency treatment is directed at addressing the most life threatening conditions first, and the dog’s management was appropriately based on this principle.
The owner and carer allege that the dog was “put in a cage and left to die”, and cite the presence of blood soaked bedding as evidence. The dog’s wounds were not treated immediately by the practitioners upon its admission and hospitalisation at the clinic. It was determined that treatment and stabilisation of the hypovolaemic shock was the most vital priority and that without this treatment the dog would not survive. While unsightly and distressing for the owner and carer to view, debridement of the wounds was not an option at this stage. There was no active haemorrhage from the wounds, due in part to both the severe shock and the age of the wounds, and the wounds were significantly contaminated and already showing signs of necrosis. Treatment of the wounds would have required general anaesthesia (to allow sufficiently rigorous debridement of the wounds and the absence of pain), which was not an option at this stage given the dog’s critical condition.
The dog’s wounds did start oozing a blood tinged discharge during his hospitalisation, causing the soiled bedding. This discharge was not active haemorrhage but rather an open wound exudate, resulting from the severe tissue damage and infection. The dog’s wounds were not cleaned or bandaged during his hospitalisation as it was deemed that this would cause unnecessary pain and suffering and may have exacerbated infection prior to any surgical debridement. The Board accepted that bandaging the wounds would have been of no benefit given the degree of contamination to the wounds.
Options
On admission to the clinic referral to a 24 hour emergency facility was offered, but declined, on financial grounds. The carer was made aware that the clinic is not staffed overnight.
The dog’s owner and carer were concerned that his wounds were not attended to by staff at the original clinic, and yet the wounds were treated by staff at the second clinic on his admission there. The Board considered that, given the dog’s life threatening condition, surgical debridement of the wounds under general anaesthesia was not an option while the dog was in the care of the original clinic, and therefore was not presented to the owner and carer as an option. The dog required stabilisation of his condition before treatment of his wounds could be a consideration. The dog was hospitalised for approximately seventeen hours, during which time his condition was able to be managed to such an extent that superficial debridement of the wounds was able to be performed at the second clinic. Surgical debridement of the wounds under general anaesthesia was not attempted by the second clinic until (approximately) twenty hours after his admission, during which time the dog was managed using the same treatment regime as instigated at the original clinic. The Board considered that the fact that the dog suffered cardiac arrest while under general anaesthesia at the second clinic was confirmation of his acute surgical risk.
Based on the severity of the wounds to both forelimbs, and the rejection of referral as an option due to financial reasons, the veterinary practitioners who examined the dog at the first clinic recommended euthanasia. Four practitioners examined the dog and all agreed that, due to the severe damage and devitalisation of both forelimbs, the limbs were not salvageable at their clinic. Due to the dog’s size, bilateral amputation was not considered a reasonable option. While the staff at the second clinic undertook treatment in an attempt to save the limbs, the Board noted that the dog did not regain function of his forelimbs during his period of hospitalisation. Given the severity of the wounds and the dog’s critical condition, the Board considered that euthanasia was an appropriate option to be presented to the owners.
Ownership
The Board were of the opinion that difficulties establishing ownership resulted in problems communicating options and obtaining consent for ongoing treatment while the dog was in the care of the original clinic. The dog was presented to the clinic by the agent, who claimed (as evidenced in the clinical record) to be caring for the dog while his owner was away. The agent was, at this stage, unable to provide the owner’s full name or contact number. When presented with options for treatment, the agent stated (documented in their complaint form) that they could not make a decision in relation to the dog’s medical care as they were not the owner. The dog’s owner was not able to attend the clinic until the following afternoon. The Board considered that the staff acted appropriately in stabilising the dog until the owner could attend and be involved in decision-making for ongoing care. The Board acknowledged the difficulty inherent in not being able to communicate with the animal’s owner at such a critical time.
With the information available, the Board found no evidence of unprofessional conduct.
Relevant guidelines