College Connection Fall 2016 - Page 6

college connection LEARNING IN PRACTICE Members of the veterinary profession have a responsibility to uphold standards to ensure the public has access to safe, quality veterinary care. When those standards are compromised, the College responds. Every veterinarian can learn from these situations and publishing the details of complaints received and resolved is intended to support that learning. The example below is taken from an actual case and is offered as a self-reflection tool to improve practice across the province. MEMBER GIVEN GUIDANCE ON MEDICAL RECORDS, STEROID USE CASE SUMMARY probable chronic renal disease. The client’s dog had been a regular patient and was seen for routine preventative health care, anal sac issues, and itchy skin. The member administered repeated corticosteroid injections. With each injection, the dog seemed to become more lethargic. In January, the member saw the dog for itchy skin and increasing lethargy. The member radiographed her chest and determined the dog was in early congestive heart failure. The member administered a corticosteroid, DepoMedrol, and a long-acting injectable antibiotic to address the itchy skin. The client alleged the member failed to discuss the side effects or the risks of the steroids; failed to perform appropriate tests when treating the dog with steroids; misdiagnosed the dog with a serious heart condition; and failed to make or keep proper medical records. Following this appointment, the client took the dog for a second opinion. Veterinarian A performed a physical examination, and repeated radiographs which revealed an enlarged liver, and mild enlargement of the heart with a bronchiolar pattern over the caudal, dorsal lung field, and an absent cardiac waist, but no fluid was seen. Blood was drawn for complete blood count, chemistry panel, thyroid levels, and a urinalysis was completed. Results were validated at an external laboratory, and it was determined multiple enzymes associated with the liver were elevated, notably the Alanine Transferase. This enzyme elevates as liver cells are damaged/dying. Pre and post prandial serum bile acids were also found to be elevated, indicating the liver was not working appropriately. Veterinarian A began treatment with antihistamines, S-AdenosylMethionine, vitamins, prescription diets and medicated shampoos. The dog was thought to have a steroid induced hepatopathy (liver disease resulting from chronic steroid use) so an internal medicine specialist performed a physical examination, abdominal ultrasound, and assessment on the dog. The findings were consistent with hepatopathy, enteropathy of the duodenum and cecum, probable chronic active pancreatic disease, and 6 / College Connection CASE CONSIDERATIONS The panel found it difficult to evaluate or support the member’s treatment decisions as the medical records lacked sufficient detail. Medicating the dog orally was difficult, which does complicate treatment. Additionally, the member recommended a food elimination trial, but the required time frame to determine success was never achieved. Neither of these factors warranted repeated, chronic doses of dexamethasone and Depo-Medrol, especially without educating the client on the implications of repeated steroid use. The panel found over three years, the dog received eight injections of dexamethasone either alone or with Depo-Medrol. There was one note in the medical record that the pros/ cons of steroid injection were discussed with the client. The panel did not believe this discussion included the side effects of steroids when used acutely or chronically, only the difference between oral and injectable steroids. With regard to the specific drugs and doses of dexamethasone and Depo-Medrol, the panel felt it important to elaborate on their use in this case. Depo-Medrol is a ‘long acting’ corticosteroid and the usual goal is to use as much as required and as little as possible for as short an amount of time as possible. Most of the time, the dog was administered 20mg at each dose. The panel agreed this dose was high, for the size of the dog, and repeated too often for safe use, given what appeared to be mild clinical signs. Given the number of times and length of time the dog received steroid injections or oral tablets, it would have been appropriate to recommend some form of monitoring of internal organ function. However, there was no documentation of any testing other than Heartworm/Tick testing as being performed, offered, or declined. With regard to the member’s diagnosis of early heart failure, the panel noted it may have been prudent for the member to consider recommending other diagnostics to support a diagnosis which is difficult to make on radiographic findings alone. The panel was also of the opinion the member’s medical records in this case failed to meet the requirements set out by the College with regard to record keeping. CASE OUTCOMES The Complaints Committee panel decided the allegations did not warrant a discipline hearing. The panel had concerns with the member’s use of cortiscosteroids without advising the client of potential side effects; the use of the injectable antibiotic Convenia; and the member’s failure to maintain a comprehensive medical record. The member agreed to participate in a Mutual Acknowledgement and Undertaking to improve performance in his practice. Through participation in the undertaking, the member established a protocol to ensure clients are informed about diseases, conditions or procedures. The undertaking included participation by the member and staff in the College’s medical records workshop and a peer review of eight medical records. As well, the membe r was mentored on specific standard of care issues related to the case and prepared a paper summarizing learnings.