Case study: Navigating emergency care, after hours

background a six year old dog was taken to a veterinary clinic for emergency care, after hours because it was struggling to breathe the veterinarian performed a physical examination and found the dog was very dehydrated, and had pale and tacky mucus membranes they suspected the dog had internal bleeding or a ruptured spleen and recommended further testing a blood test and ultrasound were performed at the clinic aside from an increase in white blood cells, the biochemistry results did not show anything concerning however, the ultrasound showed free fluid in the abdomen a sample of the fluid was taken using an ultrasound guided procedure the sample contained 5ml of blood tinged fluid the veterinarian explained to the dog’s owner that the prognosis was poor as the dog had blood in the fluid and gave them the option of euthanising the dog or performing an exploratory laparotomy they explained the significant risks involved with any surgical procedure, and the client chose to proceed the veterinarian obtained and documented the client’s informed consent shortly after being sedated, the dog suffered a cardiac arrest, with the likely cause of death being septic peritonitis the complaint the dog’s owner complained to the vet council, saying that the veterinarian misdiagnosed the dog and did not alleviate the cavity pressure which was impacting the dog’s breathing they also complained that the vet suggested euthanasia as an option before they had performed the laparotomy, and thought that an incorrect dose of anaesthetic was administered the complaint was referred to the complaints assessment committee (cac) the cac is a preliminary screening body, that decides what should happen after a complaint has been made about a veterinarian the cac may proceed with a formal investigation and decide what steps, if any, need to be taken after considering the particulars of a case in making a decision, the cac considers whether the veterinarian has met the standard to be reasonably expected of a competent veterinarian practising in a similar context what professional standards are expected? the code of professional conduct https //hub vetcouncil org nz/code of professional conduct requires veterinarians to obtain a client's informed consent before proceeding with a proposed treatment or course of action this process involves the veterinarian providing information in an understandable way and allowing the client enough time (where appropriate) to ask any questions they have, and to choose to follow the recommendations or not the consent process needs to be adequately documented the vet council’s competency standards and performance indicators for veterinarians https //hub vetcouncil org nz/competency standards and performance indicators for veterinarians require vets to obtain and record sufficient information for analysis, diagnosis, and retrieval indicators of this standard include performing or arranging tests and procedures to make a diagnosis a veterinarian would be expected to discuss a potential diagnostic pathway and their recommendations for further investigation, if appropriate they should talk through the different treatment options for an injury like the one described in this case ideally, they would also discuss the spectrum of care, taking into consideration the client’s opinion and resources the code expects that any potential side effects or adverse outcomes from the proposed treatment plan are also discussed how it was managed when reviewing a complaint, the cac measures the veterinarian’s conduct against the standard that is expected of a veterinarian practising in similar circumstances the cac considered the veterinarian’s differential diagnoses were appropriate, given the results of the physical examination, blood testing, and abdominal ultrasound in this case, the cac felt the veterinarian’s recommendations were reasonable because of how unwell the dog was when it arrived at the clinic, and the cac was satisfied that the veterinarian communicated the poor prognosis to the client the cac noted that a presumptive diagnosis of a bleeding abdominal mass or a splenic rupture was reasonable in the circumstances of the case further investigation would have been needed to reach a definitive diagnosis the cac reviewed the diagnostic pathway, anaesthetic protocol and treatment, and found them to be appropriate in the circumstances in the cac’s view, an exploratory laparotomy and surgery would be an appropriate next step while the client requested that the fluid discovered by the ultrasound be drained from the abdomen, the veterinarian’s clinical examination revealed that the abdomen was soft and non painful the anaesthetic drugs included methadone and acepromazine, which were administered intravenously, and the patient was induced with alfaxan, which the cac felt was appropriate the veterinarian also contacted a colleague for advice and a second opinion the cac was satisfied that there had been a discussion between both parties about the spectrum of treatment options, evidenced by the signed consent form for the exploratory laparotomy, after the veterinarian communicated the risks of placing the dog under general anaesthetic traditionally, the nature of emergency care veterinary services differs from the services offered by a client’s regular veterinarian the code outlines the veterinarian’s professional duty to take steps to relieve unreasonable or unnecessary pain or distress in animals under their care the cac considered that the veterinarian demonstrated a high level of competency, being presented with a patient in an extremely poor state of clinical health, outside of regular business hours the findings on the post mortem examination were consistent with septic peritonitis the cac agreed that an exploratory laparotomy and surgery would still have been indicated as the next step, regardless of whether there was a presumptive diagnosis of neoplasia, splenic rupture or septic peritonitis decision the cac decided that the veterinarian acted accordingly within the expected standards, and no further action was taken it commented that the veterinarian demonstrated a high level of competency and had a professional approach to the case, especially considering the challenging circumstances learnings for the profession the vet council has prepared a range of case studies that you can read on the hub, which demonstrate how complaints and other concerns are managed, and what the profession can learn from them they are a good way to see how veterinary standards and the code are applied in various situations you can also read the code of professional conduct and the competency standards and performance indicators for veterinarians on the hub all veterinarians in new zealand must meet these standards the hub brings all of our technical guidance and veterinary standards together in one place, allowing for easy reading and research it also makes searching for answers to common questions simpler