Case study on the importance of providing timely treatment
Published in the May 2016 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.
Summary
A puppy was presented to Dr K with vomiting and diarrhoea. The puppy was hospitalised overnight, and was found to be deceased the following morning. The owners allege that Dr K did not undertake reasonable diagnostic investigation to ascertain the cause of the puppy’s condition, and did not initiate reasonable treatment.
After a preliminary investigation, the matter was referred to an informal hearing into the professional conduct of Dr K.
It was alleged that:
- Dr K’s clinical management of the puppy was inadequate.
- Dr K’s communication with the puppy’s owners was inadequate.
Dr K was found to have engaged in unprofessional conduct, and the Panel determined that Dr K be counselled.
Counselling is one of the determinations that may be made following a finding of unprofessional conduct. It is a formal process during which the veterinary practitioner is informed of how their conduct failed to meet the minimum required standard and how that standard might be met in future. The Panel may counsel in any way it sees fit. The counselling may be oral, written, given immediately or within 28 days of the determination. It becomes a matter of permanent record on the veterinary practitioner’s file and may be referred to in any future Hearing or action taken by the Board.
Reasons for panel's findings
The informal hearing panel made its finding based upon the following reasons:
The puppy was purchased from a pet shop. The owners reported that he seemed subdued when they collected him, which was in contrast to his demeanour when viewed a few days prior to purchase. Upon arrival at their home the owners reported that the puppy developed diarrhoea, which continued over the following day. The puppy was presented to a local veterinary clinic. A clinical examination did not reveal any abnormalities. The puppy was wormed and it was recommended that he be fed bland food until the diarrhoea resolved.
The puppy was re-presented to the clinic later that afternoon as he had begun vomiting and passing bloody diarrhoea. A repeat clinical examination revealed the puppy to be depressed (in comparison to his presentation earlier in the day), with a slightly increased capillary refill time (in comparison to earlier) and tacky mucous membranes. Abdominal palpation elicited severe pain. His body temperature was marginally increased and bloody faeces were evident on the thermometer. A parvovirus test was undertaken, the result of which was negative.
It was recommended that the puppy be hospitalised for intravenous fluid and antibiotic therapy, analgesia, and supportive care. Diagnostic investigation was recommended to determine the cause of the puppy’s symptoms, including (but not limited to) faecal analysis to test for parasites (hookworm, etc.), coccidia, giardia, salmonella, campylobacter, coronavirus, etc., and blood testing to check packed cell volume and total protein levels.
Subsequently, the owners phoned the pet shop to advise of the puppy’s condition, and the veterinary practitioner’s findings and recommendations. The pet shop owner advised the owners that for the pet shop to cover the costs of any veterinary treatment the puppy would need to be treated by their nominated veterinary practitioner, Dr K. Therefore, the puppy was taken directly to Dr K’s clinic by his owners. Prior to leaving the local veterinary clinic, the puppy was given an injection of Temgesic® to relieve his pain.
Upon presentation at Dr K’s clinic, the puppy was admitted to hospital. The clinical examination recorded by Dr K did not reveal any abnormalities apart from a depressed demeanour and smelly brown diarrhoea with mucous. According to the clinical record Solvasol®, Onsior® and Cerenia® were administered upon admission. The puppy was checked overnight by Dr K. At 11.00pm no abnormalities, besides depression, were noted and no treatment was administered. At 3.00am, 20ml of subcutaneous fluid was administered and glucose was rubbed onto his gums. The puppy was found deceased later that morning.
Allegation 1: that Dr K's clinical management of the puppy was inadequate
The informal hearing panel had several concerns about the management of the puppy’s condition.
Dr K informed the panel that in their opinion the puppy did not seem particularly unwell. According to Dr K, they did not observe any haemorrhagic diarrhoea or abdominal pain, either at presentation or during the time the puppy was under observation. Dr K reported that they were advised by both the puppy’s owners and the owner of the pet shop that the puppy was suffering from diarrhoea, and based upon that advice and the results of clinical examination they treated the puppy accordingly.
The puppy’s owners stated that they informed Dr K that the puppy had been vomiting and suffering from haemorrhagic diarrhoea. The owners say a faecal sample collected at the local clinic was presented to Dr K and the owners claim that this sample was maroon in colour due to the presence of blood. They also reported that at the time of presentation the puppy’s bedding and hind legs were soiled with bloody diarrhoea. Dr K denied any knowledge of either a faecal sample or the soiled bedding. The panel was concerned that Dr K did not seem to take into account the recent history of haemorrhagic diarrhoea and rapid deterioration in the puppy’s condition in their management of the puppy’s care. Even if the puppy was not currently exhibiting signs of haemorrhagic diarrhoea, the panel considered that the fact that he had been suffering from it only a short time prior to his presentation to Dr K was relevant and should have been a consideration in the management of his condition. The panel found no evidence to suggest that Dr K was not made aware of the fact that the puppy had been suffering from haemorrhagic diarrhoea and/or the resulting recommendations made for care by the local veterinary clinic. In their response to the Board, Dr K stated that they had asked the owners to confirm that their vet had said he was quite sick and, when the owners responded in the affirmative, had said, 'let’s keep our fingers crossed that it’s not that bad'. The panel was of the opinion that this conversation supported the owners’ claim that they had informed Dr K of the history, findings, and recommendations from the original veterinary practitioner.
The clinical examination of the puppy did not take place until after the owners had left. Dr K indicated that their examination did not reveal any abnormalities, apart from a depressed demeanour, which they attributed to the recent administration of Temgesic® and some smelly brown diarrhoea with mucous. Based on these signs, Dr K treated the puppy’s illness as a simple case of diarrhoea. The puppy was administered antibiotic, antiemetic, and anti-inflammatory injections upon admission. No further treatment was provided until 3.00am the following morning, when 20ml of subcutaneous fluid was administered and glucose rubbed onto the gums.
The panel considered that Dr K’s preliminary assessment of the puppy’s condition was inadequate. While the owners stated that they had discussed the puppy’s condition with Dr K, the clinical record stated, 'no history provided…' The history is an important and relevant part of any clinical assessment. Without an adequate history, the practitioner’s assessment will be entirely based upon physical examination, the results of which are specific to a moment in time and may not reflect the clinical picture in its entirety. While Dr K assessed the puppy’s condition to be stable, there were aware that the puppy had been assessed by another veterinary practitioner only a short time before, and that their assessment was that the puppy’s condition was potentially very serious (as evidenced by their question to the owners: 'your vet said he was quite sick?'). The panel considered that knowledge of the recent assessment by another practitioner, which differed quite significantly from his/her own, should have raised questions regarding the puppy’s prior history and clinical status and resulted in Dr K taking measures to obtain a complete clinical history (whether from the owners and/or the other practitioner). This is not to say that a practitioner must treat an animal based upon another’s assessment or judgement, only that a thorough history contributes to the clinical management of a case. In this case, the panel found that Dr K had proceeded without obtaining all possible information with which to make a clinical assessment. Had all possible information been obtained and considered by Dr K, the clinical management and outcome of this case may have been different.
A puppy with diarrhoea (especially haemorrhagic diarrhoea) can deteriorate extremely quickly and death is not an uncommon occurrence in such cases. The panel considered that Dr K should have been aware of this fact and managed the puppy’s case accordingly. The panel considered that the signs displayed by the puppy (and communicated to Dr K by the owners) indicated a more severe systemic illness than a simple case of diarrhoea, which is generally self-limiting, and that as such a more proactive diagnostic and therapeutic intervention was warranted. The panel was unable to reconcile Dr K’s assessment of the puppy as being stable and not particularly unwell with that of the veterinary practitioner who had examined the puppy only a short time before (<1 hour) his presentation at Dr K’s clinic.
No diagnostic investigation was undertaken by Dr K in an attempt to ascertain the cause of the puppy’s symptoms and/or assess the severity of his condition. Dr K said that external laboratories were shut for the evening, precluding much diagnostic testing. While acknowledging this fact, the panel considered that given the lack of any signs of improvement in the puppy’s condition, some basic in-house testing may have been beneficial to assess the puppy’s condition, the results of which may have identified that a change to the management plan was indicated.
While Dr K expressed surprise at the puppy’s death, the panel considered that in such a young animal with limited physiological reserve death was a potential consequence and it is due to this possibility that the clinical management undertaken in such cases should actively support physiological maintenance and recovery.
Dr K informed the panel that as a result of this incident they no longer admitted pet shop animals to hospital without conducting a clinical examination with the owners present.
Allegation 2: that Dr K's communication with the puppy's owners was inadequate
The panel found that Dr K did not take reasonable steps to obtain a thorough history of the puppy’s symptoms and prior clinical assessment and that (as documented above) this resulted in a clinical management plan which was formulated without all available and relevant information.
As Dr K did not perform a clinical examination on the puppy until after the owners had left the clinic, the examination findings, options for treatment, and recommendations were not communicated to them. Dr K stated that it was their opinion that, by leaving the animal in the care of the clinic, the owners were consenting to whatever treatment they deemed necessary.
The panel considered that there were several treatment options available to address the puppy’s condition and these options should have been presented to the owners with details of the associated prognosis, potential complications, and consequences, so they could make an informed decision in regards to the puppy’s ongoing care. The panel further considered that options for overnight hospitalisation should also have been communicated to the owners. There is no evidence to suggest that the owners were made aware of the level of overnight supervision which would be provided by Dr K, or of other options for overnight care (such as referral to a 24-hour clinic for which the owners would have borne the cost) if they were not agreeable to the level of supervision offered at Dr K’s clinic.
Conclusion
In conclusion, the informal hearing panel was of the opinion that an animal presented to the clinic under the pet shop warranty should not be treated any differently to that of a normal, client-owned patient. The same obligations for clinical assessment, communication of findings with options for care and standard of clinical management exist regardless of the fact that veterinary service is being provided subject to warranty.
Relevant guidelines