Medicine

The Realities of Human Error In Veterinary Surgery

December 19, 2015 by Sarah Boston, DVM, DVSC, DIPL ACVS

Helmut* was one of my cancer patients. He also had a painful, nonvisual eye. The eye ended up giving him more trouble than the tumor and the owner elected to have it removed. She had it removed by a board-certified ophthalmologist (not at the hospital I work at, I hasten to add). There was a horrible mistake made. The normal, visual eye was removed and it wasn’t until after it was over that the veterinarian realized the mistake.

The client received a phone call during surgery to ask her what she wanted to do. She said to go ahead and remove the painful eye, because it was nonvisual anyway and it was affecting his quality of life. She then tried her best to rehabilitate her newly blind dog, but he didn’t adjust. He was almost deaf as well, and the acute and complete loss of his vision was too much for him. She euthanized him several weeks later, right after Christmas last year. This was and is a nightmare for all involved, especially for Helmut.

How could this happen? And, I am sure you are thinking. Who did this? Well, to answer the second question, it doesn’t matter and to answer the first, anyone could have made this mistake. It was human error. There is a culture of shame and blame in veterinary and human surgery that prevents us from talking about medical errors. It is so much easier to assign the blame to an individual, rather than a system or institution. Wrong site and wrong side surgeries happen in both veterinary and human surgery.

[tweetthis]A culture of shame and blame in veterinary surgery prevents us from talking about medical errors. [/tweetthis]

Could this have been prevented? Absolutely. Dr. Atul Gawande has worked with a team and the World Health Organization to develop an exquisitely simple system to prevent errors like this in human surgery, a surgical checklist.

Checklists are used extensively in the airline industry to guard against human error. They are new to human and veterinary medicine, which shocks most people in the airline industry. The checklist is there to ensure that the routine things that are easy to forget or miss are systematically communicated and verified. Confirming the patient’s identity and surgical site/side, ensuring that antibiotics were given in a timely fashion, ensuring that the team has discussed potential complications or steps that are not routine preoperatively, and counting instruments and sponges.

Dr. Gawande tested the surgical safety checklist and found a significant reduction in morbidity and mortality at six different hospitals in the developed and developing world. He wrote about the surgical checklist in his book, The Checklist Manifesto. (I highly recommend this book!) I started using a checklist as soon as I finished reading Atul Gawande’s book in 2010. Now I can’t imagine doing surgery without one.

The effect of the checklist is several-fold. It focuses and empowers the team, it allows for a double-check system, it is an efficient way to go over the critical information about a case in an organized fashion, it ensures that sponges and instruments are counted in and out, and it changes the work culture for the better. The medical term “retained” surgical instrument is an indication of the bizarre blaming culture in medicine. In this case, the abdomen is blamed for actively hiding the instrument inside, rather than the surgeon forgetting it in there.

Since the surgical safety checklist came out, there has been a flurry of papers in human medicine confirming its efficacy in reducing complications in different areas of surgery. What followed is another flurry of papers on implementing the checklist and how to deal with institutional or personnel resistance to the checklist. Surgeons often resist because they are offended by the suggestion that they might make a mistake and they complain that pausing for the checklist will slow them down. The checklist is actually a faster and more efficient way to convey information once it is implemented.

I would argue that you don’t have time not to use the checklist. Further, the checklist is not there to protect incompetent people. Incompetent people will be incompetent with or without a checklist. It is there for people that are people. We all get tired, make mistakes, get distracted, rush when we shouldn’t rush, or forget to let team members know something that may improve the outcome in a case.

Most communication failures in medicine are due to either occasion or audience. Occasion, meaning that the timing of the information was suboptimal, and audience, meaning that the information was not conveyed to relevant team members. The checklist helps with this because it brings the team together at timely breaks to ensure that everyone is on the same page at the right time. The other less common communication failures include: content, meaning that the information is wrong, (checklist may not help here) and purpose, meaning that you work with a dick. (Checklist can not help you with this either.)

So, if you are not already, consider bringing a checklist system into your surgical practice. It will bring order to the chaos on your busy days. It will make your technicians happy because it will help them to do their jobs better. It will help to keep your procedures moving. It will improve the communication of your whole team. Most importantly, it may help prevent you from ever making the mistake that Helmut’s veterinarian made.

[tweetthis]You don’t have time not to use the checklist.[/tweetthis]

These veterinary horror stories rip through our profession and become legends of veterinary lore. Usually, they are accompanied with an unhealthy dose of shame and blame and they lack a concrete method to prevent these errors. That is ulcer-inducing and wholly unhelpful. Medical errors and adverse events are a part of veterinary and human medicine. Surgical checklists can help us to pick up on the preventable ones so that a wrong side surgery becomes a near miss in your practice and not a devastating surgical complication.

*Name of pet has been changed

One Question Can Save A Cat’s Life

November 29, 2015 by Dr. Andy Roark Community

What is the single most important question to ask at every feline office appointment? I imagine that you may have several, depending on the circumstances or maybe on your experiences. But I think there is one question that needs to be asked at every non-emergency (or euthanasia) appointment.

Let’s run a sad but familiar scenario. Susan comes in with her cat, Mouser. She is upset because Mouser has been urinating in the house and both she, and her partner Brian, have had enough of it. She is angry at Mouser and doesn’t understand why he is doing this. Is he is punishing them? They give him a good and loving home, he gets fed good food….Susan is frustrated and angry. She resents being put into a situation where she has to choose peace and harmony and a nice home over her cat. But, here she is, and she sees her only option as “getting rid of” Mouser.

You ask when she first noticed Mouser peeing in the house and she tells you that it was about eight or so months ago. “How often is he peeing inappropriately?” “Several times a week,” she says, “with it happening more often lately.” You find out that the problem is mostly manifested as spraying rather than horizontal voiding. “What was the final straw, the point that pushed you over the edge with this,” you ask and she replies that his spraying on her partner’s vinyl records and peeing on his sports bag last night did them in. She figures it was about the 71^st time he had sprayed.

[tweetthis]What is the single most important question to ask at every feline office appointment?[/tweetthis]

After this, you perform a physical exam, collect urine for a urinalysis and give Susan’s family a “time out” from Mouser by boarding him at the clinic while you try to ascertain if there is a physical cause before addressing stressors in the home that may be the source for Mouser’s anxiety. But sometimes, it is too late for the clients to allow the perpetrator back into the home: the bond has been broken.

Shelters work hard to find forever homes. We want to help keep these cats IN their homes, rather than have them bounce back to the shelter or be killed. The statistics for surrender to shelter for behavior problems are sobering, especially when we, as members of the cat’s healthcare team, can prevent it.

So let’s replay this scenario. When did this problem start? At least eight months ago, possibly longer given the fickleness of human memory and their lack of concern at that time. Since then, there was some level of spraying that the client was able to cope and live with. It helps to identify what that allowable frequency is, because we can’t guarantee that we can eliminate the behavior completely. We can address stressors and unmet needs (see AAFP and ISFM Feline Environmental Needs Guidelines), we can consider pharmacological and pheromonal therapy, and, with an engaged family and clinic team, there will generally be a happy ending.

[tweetthis]The statistics for surrender to shelter are sobering, especially when we can prevent it.[/tweetthis]

But did it ever have to go this far?

What if, at every visit, we asked one simple question: “Has your cat urinated or defecated somewhere in the house other than in the litter box?” If we ask this question as part of every visit, we can pick up the problem before it becomes a problem … for the clients. We can pick it up on the first or 4^th or 15^th or 70^th occasion, rather than on the 71^st when it has tipped the scale of tolerance.
Cats do not spray out of spite. There is always a reason. It may be medical (idiopathic cystitis, arthritis, diabetes, etc.), or it may be a manifestation of distress due to unmet needs that the client isn’t aware of. (See AAFP and ISFM Guidelines for Diagnosing and Solving House-Soiling Behavior in Cats)

All of this needs to be discussed and carefully evaluated, but you have a better chance of helping Mouser, before the client’s fuse has burnt out.

So let’s do it. Let’s start making this question part of every visit: “Has your cat urinated or defecated somewhere in the house other than in the litter box?” I’ll bet we can save lives and improve happiness.

[tweetthis]Cats do not spray out of spite. There is always a reason.[/tweetthis]

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

Margie Scherk graduated from the Ontario Veterinary College in 1982. In 1986 she opened Cats Only Veterinary Clinic in Vancouver, practicing there until 2008 when she retired from regular practice. While in practice, she published several clinical trials, including the first paper on transdermal fentanyl patch in veterinary medicine. She has written many book chapters, co-edits the Journal of Feline Medicine and Surgery, has served extensively on committees with the AAFP, North American Vet Licensing, Winn Feline Foundation, WSAVA and ABVP. She is a Paw Project advocate, hoping to end declawing in Canada. She continues to assist colleagues with case management and enjoys teaching about all things feline, including improving interacting with cats, analgesia, nutrition, gastroenterology and kidney disease.

I Missed A Tumor In My Own Veterinary Technician’s Dog

March 18, 2015 by Andy Roark DVM MS

I messed up. I missed a tumor in my own veterinary technician’s dog. How did I let this happen? How did I fail Smokey and Amanda?

Smokey was my inspiration for a new cancer awareness program called See Something, Do Something. I am on a mission to help us all detect tumors earlier – whether you are a veterinarian, veterinary team member, or a pet owner.

At the time, Smokey was a 10-year-old white Pit Bull that belonged to one of my technicians, Amanda. I adored them both. Smokey was one of those amazing, soulful dogs that spread sunshine with every wag of his tail. Everyone who met Smokey loved him. He was Amanda’s once-in-a-lifetime-dog.

I had aspirated over 10 skin masses on Smokey over the years, and the masses had always been benign fatty lipomas. [An aspirate is when we poke things with a small needle and then look at the cells and fluid we get out under a microscope.]

When Amanda mentioned she was bringing Smokey in to check out a new mass a few weeks earlier, we all expected it to be the routine: a quick aspirate, fat on the microscope slides, give a treat to Smokey, collect some wags and kisses, and on his way.

The first day Amanda brought Smokey in, the clinic was so busy that we never got to Smokey’s aspirate. But none of us were worried because we assumed it was just another benign lipoma.

When Smokey returned the following week, I examined the 5 cm mass that was deeply attached to the underlying tissue on his left flank area. As I did my aspirate, I could see blood collecting in my needle and syringe. I immediately knew this was not a lipoma. I aspirated the mass in a few more areas, and we submitted the slides to the lab for cytology.

I told Amanda that my clinical hunch was a tumor. Tears welled up in her eyes.

As veterinary professionals, we deal with cancer in dogs and cats every day but nothing can prepare you when it is YOUR pet. I could see Amanda’s mind start to race and shut down at the same time. I gave her a huge hug, and we waited anxiously overnight for Smokey’s cytology results.

The cytology came back as a soft tissue sarcoma. Soft tissue sarcomas, or STS, are malignant
(cancerous) and develop in a variety of connective tissues. They can be found all over the body, from head to trunk to paws. The majority of these tumors are aggressive locally, which means they dig into the neighboring tissues. They are also prone to come back if they are not removed with wide margins.

The good news is that the low and intermediate grade versions of these tumors typically don’t metastasize, or spread. Low and intermediate grades of soft tissue sarcomas are very treatable. So surgery can be curative if the mass can be removed completely.

For Smokey, the next step was a biopsy to confirm the tumor type and help our soft tissue surgeon appropriately plan his surgery. I ran blood and urine tests, and ordered chest X-rays and an abdominal ultrasound to make sure the cancer hadn’t spread – all clear!

On surgery day, Smokey had a CT scan to get a better idea of the size of the tumor. These cancers are famous for having tentacle-like projections that can extend for centimeters away from the mass. If we leave the tumor tentacles, the tumor will likely regrow.

To avoid those tentacles, these tumors generally require 3-centimeter margins (more than an inch) around the tumor and a plane of tissue underneath the tumor. Smokey’s tumor thus required a really big surgery: for a 5-centimeter tumor, the incision should be at least 11 cm (or 4.3 inches).

Smokey’s surgery went well. He spent 2 days in our ICU recovering, and we anxiously waited for his biopsy report. The biopsy report confirmed GREAT NEWS: a low-grade (grade 1) hemangiopericytoma with wide, clean margins. He did not need more treatment – no post-operative radiation or chemotherapy. I just recommended regular monitoring of the scar and periodic chest X-rays.

Even though Smokey’s surgery had a happy ending, his malignant tumor really hit me hard. In hindsight, if we had aspirated this earlier when the mass was smaller, his surgery would have been simpler. How could I, a cancer specialist, have missed this tumor? And did I misguide Amanda?

Were there guidelines I had forgotten? I pulled out cancer books, journals, and cancer notes from my medical oncology residency. No, there are no guidelines for veterinarians or pet owners for when to aspirate or biopsy a mass on a dog or cat. The recommendations for doing an aspirate include generalities – “recommend if a mass is changing in size or appearance, or bothering the patient.“

Owners are often told to “keep an eye on it.” But what does that mean? Keep an eye on it for how long? How much can it grow before we should do something?

I hear all too often that a mass does not look or feel malignant. The pet owner should just monitor the mass and wait until it is bothering the pet. This is not good enough!

When tumors grow, what could have been removed with a simple surgery may now require a bigger surgery and radiation or chemotherapy afterwards. Even worse, the tumor may become too big to be removed or treated at all.

No one, not even a cancer specialist like me, can look at a mass and know what it is. We must do better. We must find tumors earlier when they are small. We must aspirate them. That’s where See Something, Do Something comes in.

See Something, Do Something:
See something – if your dog or cat has a mass that is the size of a pea (1 cm) and has been there 1 month,
Do something. Go to your vet and get it aspirated (or biopsied)

Do not get complacent like I did. Even after many benign aspirates, the next one can be malignant (like Smokey’s was).

See Something, Do Something. Why wait? Aspirate.

About Sue Ettinger, DVM, DACVIM (Oncology)
Dr Sue Cancer Vet

Dr. Sue Ettinger, ACVIM (Oncology), is a boarded veterinary medical cancer specialist. She attended Cornell University College of Veterinary Medicine. As a Diplomate of the American College of Veterinary Internal Medicine (Oncology), and she is 1 of approximately 300 board-certified veterinary specialists in medical oncology in North America. Dr. Ettinger is currently the head of the Oncology Department at the Animal Specialty Center in Yonkers NY.

Also known as Dr Sue Cancer Vet, she is a book author, radio co-host, and Certified Veterinary Journalist. Dr. Sue is the co-author of the Second Edition of The Dog Cancer Survival Guide, and she co-hosts The Pet Cancer Vet, an internet radio show on radiopetlady.com. From 2011 to 2014, Dr. Sue was a regular contributor to the blog, www.dogcancerblog.com. She lives in Westchester NY with her husband, a veterinary internist, their two sons, their goofy black Labrador, Matilda, and their dog-loving orange cat, Jeter.

Dr. Sue is passionate about raising cancer awareness, and she has developed See Something, Do SomethingTM to promote early cancer detection and diagnosis. The sooner we determine whether a mass is cancerous and should be removed, the better for our pets. Most skin and subcutaneous tumors can be cured if diagnosed early when masses are small. Early detection saves lives.

She can be found on social media at www.facebook.com/DrSueCancerVet and @DrSueCancerVet on Twitter.

Cancer: Now What?

April 10, 2014 by Andy Roark DVM MS

In July of last year, a young couple brought their two Greyhounds to see me at the clinic. Joel, the 11-year old dog, had begun coughing over the last few days. (Toast, Joel’s faithful companion, came along for moral support.)

The couple and I talked about how the dogs were doing, and possible causes for this mild but persistent cough. As I examined Joel, our conversation drifted to work, married life and local restaurants. The room was full of smiles and laughter. Then I put my stethoscope on Joel’s chest.

His lungs sounded terrible. I immediately feared severe lung disease.

To avoid alarming Joel’s owners, I simply said, “I don’t like the way Joel’s lungs sound. Let’s take some X-rays to make sure everything’s OK.” They agreed, and I led Joel from the room as Toast looked on warily.

When his x-rays appeared on my computer screen, my heart sank. Joel’s lungs were full of soft-tissue nodules. He had metastatic cancer.

What followed was a painful and emotional conversation that I have had far too many times. I began by displaying the x-rays so I could explain my findings to Joel’s unsuspecting owners. The first thing I said was, “I’m afraid I have some bad news to share.”

Manage Veterinary Clients’ Requests for Special Treatment

November 1, 2012 by Andy Roark DVM MS

Manage Veterinary Clients’ Requests for Special Treatment

Originally Published: DVM NewsMagazine, November 1, 2011

I drop into my office chair, flip open the puppy’s chart and start frantically writing. I’m 15 minutes late for my next appointment and clenching my teeth. Even my eyelids are tensing with stress. When did I start carrying emotional tension in my face? Is it even possible to do stretches for these muscles?

With no time for a facial yoga session, I glance toward the appointment schedule for the rest of the morning. It’s packed, and it’s not looking like this day is going to end anywhere near our 1 p.m. Saturday closing time.

Before I can rush out the door to meet my next client, the phone lights up. “Dr. Roark, Ms. Nuñez is on the phone, and she says she’ll speak only to you.”

I know what this means. I have crossed paths with Ms. Nuñez before. She’s a loving cat owner but a demanding client and master negotiator. (Takes one to know one: I once talked a limo driver into loaning me his snakeskin boots when a nightclub bouncer took exception to my tennis shoes.) Our conversations feel like they should take place at Camp David.

As I press the flashing button to take the call, I run through the negotiation tactics I know she’ll use against me. Any of these sound familiar?

Get to the decision maker

If a client wants baseless discounts, waived emergency fees or complete circumvention of scheduling protocols, the doctor is whom they ask for. No one else has the authority, or lack of common sense, to make these things happen. So Ms. Nuñez insists on speaking to me directly. She’s off to a solid start.

Create a looming deadline

As soon as I pick up the phone, Ms. Nuñez jumps into the details of her visit to the emergency clinic the previous evening and the impending doom that looms over her cat, Petie.

Petie, it turns out, has had a urethral obstruction and, while he has been catheterized, Ms. Nuñez knows deep in her bones that the cat needs a perineal urethrostomy…right now. She is adamant that re-blockage is imminent and that leaving the patient at the emergency clinic until Monday is simply not an option. She feels surgery must be done immediately—but not at the emergency clinic (or at emergency prices).

Go heavy on flattery

Once she lays out the urgency of the situation, Ms. Nuñez targets my ego. She is certain, she says, that I can help her and do a better job than anyone else. I am, after all, the best veterinarian she’s ever met. (Fortunately, the stress tension in my face prevents my head from expanding noticeably.)

Understand the other party’s priorities

We, as veterinarians, deeply want to help animals. Ms. Nuñez knows that her cat’s health and quality of life are more important to me than money. She is also willing to bet that they’re more important to me than my Saturday afternoon. She uses this knowledge and ends her impressive pitch with, “Doctor, please don’t let my kitty suffer! You’ll save his life, won’t you?”

My mind races as I try to form a response.

She’s made her case so masterfully, I’m almost ready to book the after-hours appointment and risk mutiny by my technicians. But no. Today, I’ll do what makes the most sense for everyone involved, including Petie. I’ve got some negotiating strategies of my own. Here they are:

Recognize the pitch

As soon as a client demands to speak to me and me alone, I go on high alert. This is someone who’s looking to bypass the regular guidelines of the practice.

Control your heart

As her frantic story unfurls, I force my analytic brain to prevail over my warm and fuzzy side. I care about Ms. Nuñez’s cat, but I can’t let that emotion blind me to the consequences of my decision. I must also care about all the other pets who are scheduled to come in, my staff and their time, and my own family.

Understand the other side

Often, we think we know our clients’ priorities, but we rarely know the entire story. I ask Ms. Nuñez why she doesn’t want the surgery done at the E-clinic. She tells me first that it’s because she feels so good about working with me (back to the flattery), and then that the estimate is very pricey. Finally, she tells me she just doesn’t know these people, and she’s scared. Now I really understand where she is coming from.

Slow down

Ms. Nuñez has thrown a lot of information at me at once. None of it has been verified by the veterinarian she saw last night, and all of it is emotionally charged. My next goal is to get off the phone, so I can think clearly and quietly. “Did the emergency clinic fax me your record?” I ask. “I’ll review it as soon as I can and call you back in a few hours.” She nervously agrees to wait, and now I have time to unclench my face and contemplate my options.

Think through the whole scenario

After a few moments of reflection, I am certain that, though I want to help, I won’t be seeing Ms. Nuñez and Petie this afternoon. To do so would make my technicians work well past their scheduled shifts, leave my patient unsupervised after the procedure, and force me to do a solo surgery I am not comfortable with—not to mention strand my wife at home with a young child and infant. Rationally, I just can’t agree to it.

Address concerns, offer options

When I have reviewed the record, I call Ms. Nuñez back. I tell her I want to help, and that her cat’s health is my top priority in making a plan. I answer all her medical questions and then explain that I am not comfortable with the surgery, nor do I have the necessary staff available.

I tell her that I have great confidence in the E-clinic, which helps address her fears about dealing with unfamiliar people. I also tell her that I will support her in either having the surgery there or continuing supportive care until Petie can be transferred to me (and a more experienced surgeon) on Monday.

Step away

I have given Ms. Nuñez all the information she needs to make an educated decision on her pet’s care. I tell her she can think everything over, confer with the emergency doctor, and then let me know how she wants to proceed.

An hour later Ms. Nuñez decides Petie should have the surgery and come home as soon as possible. With my endorsement of the E-clinic, she feels comfortable going forward with the procedure there. She tells me that she will plan to see me when Petie needs his sutures removed.

I have no doubt she will talk me into doing it for free.

Give Us an Earful: How Do YOU Treat Aural Hematomas?

April 18, 2012 by Andy Roark DVM MS

Give Us an Earful: How Do YOU Treat Aural Hematomas?

Originally Published: Clinician’s Brief, March 8, 2012

Click here or above to read the complete How Do YOU Treat Aural Hematomas? article.

Give Us An Earful: How Do YOU Treat Aural Hematomas?

“What are you going to do this time?” my technician whispered as we looked into the waiting room. The 4 y.o. MN Bernese Mountain Dog looked back happily, then violently shook his head. The hair on the outside of his right ear was starting to re-grow, as was the fluid-filled pouch on the underside. His owner spotted me peeking around the doorframe as I tried to assess the situation, as well as the attitude of the client who was making his fifth visit in the last 8 weeks. He gave me a pained grin that said, “I like you a lot, but you really need to fix this.”

To be honest, I was (and still am) quite fond of this particular dog. However, frustration over this unresolved aural hematoma was threatening to seep into my bedside manner. During this case, I read widely on treatment options, and discussed everything from medical management to ear amputation with the owner. I tried multiple courses of steroids, ran blood work, evaluated clotting times, drained, opened, sedated, anesthetized, quilted, and asked for advice from almost every veterinarian I knew (and some that I didn’t).

Ultimately, it was a combination of steroids, quilting, and drains (and possibly prayer) that seemed to do the trick. I used an 6-week tapering course of prednisone with 1cm full-thickness sutures and a ¼-inch fenestrated latex drain, which I removed after 3 weeks. Having gone through this emotionally scarring ordeal, three things now happen whenever I see an aural hematoma. First, I develop a mild eye twitch that my technicians are starting to pick up on. Second, I preemptively warn the owner how frustrating treatment of this condition can be. And finally, I kick myself for not writing down all the great advice I was given on effective treatment of this condition the first time.

So today, for the sake of all the veterinarians that are battling (and will battle) this potentially humbling condition, I ask for your help. Please share your best advice for treating aural hematomas in the comment section below. Your words of wisdom may save a young (or not so young) veterinarian a lot of frustration!

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