1. Compendium
CompendiumVet.com | Peer Reviewed | Listed in MEDLINE Vol 31(3) March 2009
6 CE Contact Hours CONTI N U I NG EDUCATION FOR VETERI NARIANS ®
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Treatment Options
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Hypersensitivity
in Cats
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4. March
2009 Vol 31(3)
CompendiumVet.com | Peer Reviewed | Listed in MEDLINE
EDITORIAL BOARD
Anesthesia Internal Medicine
Nora S. Matthews, DVM, DACVA Dana G. Allen, DVM, MSc, DACVIM AMERICAN
Texas A&M University Ontario Veterinary College BOARD OF
Cardiology Internal Medicine and Emergency/ VETERINARY
Bruce Keene, DVM, MSc, DACVIM Critical Care PRACTITIONERS
North Carolina State University Alison R. Gaynor, DVM, DACVIM
(Internal Medicine), DACVECC
(ABVP) REVIEW
Clinical Chemistry, Hematology,
North Grafton, Massachusetts BOARD
and Urinalysis
Betsy Welles, DVM, PhD, DACVP Nephrology
Kurt Blaicher, DVM, DABVP
Auburn University Catherine E. Langston, DVM, ACVIM
Animal Medical Center
(Canine/Feline)
Dentistry Plainfield Animal Hospital
New York, New York
Gary B. Beard, DVM, DAVDC Plainfield, New Jersey
Auburn University Neurology Canine and Feline Medicine
EDITOR IN CHIEF R. Michael Peak, DVM, DAVDC
Curtis W. Dewey, DVM, MS, DACVIM
(Neurology), DACVS
Douglass K. Macintire, The Pet Dentist—Tampa Bay Veterinary
Cornell University Hospital for Animals
Eric Chafetz, DVM, DABVP
DVM, MS, DACVIM, DACVECC Dentistry (Canine/Feline)
Largo, Florida Oncology Vienna Animal Hospital
Department of Clinical Sciences Ann E. Hohenhaus, DVM, DACVIM
Emergency/Critical Care and Vienna, Virginia
College of Veterinary Medicine (Oncology and Internal Medicine)
Respiratory Medicine Canine and Feline Medicine
Auburn University, AL 36849 Animal Medical Center
Lesley King, MVB, MRCVS, DACVECC,
New York, New York
DACVIM Henry E. Childers, DVM,
University of Pennsylvania Gregory K. Ogilvie, DVM, DACVIM DABVP (Canine/Feline)
(Internal Medicine and Oncology) Cranston Animal Hospital
Endocrinology and Metabolic Disorders
CVS Angel Care Cancer Center and Special Cranston, Rhode Island
Marie E. Kerl, DVM, ACVIM, ACVECC
Care Foundation for Companion Animals
University of Missouri-Columbia Canine and Feline Medicine
San Marcos, California
EXECUTIVE Epidemiology
Ophthalmology
ADVISORY Philip H. Kass, DVM, MPVM, MS, PhD,
David A. Wilkie, DVM, MS, DACVO
David E. Harling, DVM,
BOARD DACVPM DABVP (Canine/Feline),
The Ohio State University
University of California, Davis DACVO
MEMBERS Parasitology Reidsville Veterinary Hospital
Exotics
Byron L. Blagburn, MS, PhD Reidsville, North Carolina
Avian
Behavior Auburn University Canine and Feline Medicine,
Thomas N. Tully, Jr, DVM, MS, DABVP
Sharon L. Crowell-Davis, (Avian), ECAMS David S. Lindsay, PhD Ophthalmology
DVM, PhD, DACVB Louisiana State University Virginia Polytechnic Institute
The University of Georgia and State University Jeffrey Katuna, DVM, DABVP
Reptiles
Douglas R. Mader, MS, DVM, DABVP (DC) Pharmacology Wellesley-Natick Veterinary
Dermatology Marathon Veterinary Hospital Katrina L. Mealey, DVM, PhD, DACVIM, Hospital
Craig E. Griffin, DVM, Marathon, Florida DACVCP Natick, Massachusetts
DACVD Washington State University Canine and Feline Medicine
Small Mammals
Animal Dermatology Clinic Karen Rosenthal, DVM, MS, DABVP Rehabilitation and Physical Therapy
San Diego, California (Avian) Darryl Millis, MS, DVM, DACVS Robert J. Neunzig, DVM,
University of Pennsylvania University of Tennessee DABVP (Canine/Feline)
The Pet Hospital
Wayne S. Rosenkrantz, Feline Medicine Surgery
Bessemer City, North Carolina
DVM, DACVD Michael R. Lappin, DVM, PhD, Philipp Mayhew, BVM&S, MRCVS,
Canine and Feline Medicine
Animal Dermatology Clinic DACVIM (Internal Medicine) DACVS
Colorado State University Columbia River Veterinary Specialists
Tustin, California Compendium is a
Vancouver, Washington
Margie Scherk, DVM, DABVP
(Feline Medicine) C. Thomas Nelson, DVM refereed journal. Articles
Nutrition
Cats Only Veterinary Clinic Animal Medical Center published herein have
Kathryn E. Michel, DVM,
MS, DACVN
Vancouver, British Columbia Anniston, Alabama been reviewed by at least
University of Pennsylvania Gastroenterology Surgery and Orthopedics two academic experts on
Debra L. Zoran, DVM, MS, PhD, Ron Montgomery, DVM, MS, DACVS the respective topic and
DACVIM (Internal Medicine) Auburn University
Surgery Texas A&M University
by an ABVP practitioner.
Toxicology
Elizabeth M. Hardie,
Infectious Disease Tina Wismer, DVM, DABVT, DABT Any statements, claims, or product
DVM, PhD, DACVS Derek P. Burney, PhD, DVM ASPCA National Animal Poison Control endorsements made in Compendium
North Carolina State Gulf Coast Veterinary Specialists Center are solely the opinions of our authors
and advertisers and do not necessarily
University Houston, Texas Urbana, Illinois
reflect the views of the Publisher or
Editorial Board.
98 CompendiumVet.com
m
6. March
2009 Vol 31(3) WEB EXCLUSIVES
CE ARTICLES CLINICAL SNAPSHOT
WEB
EXCLUSIVE ❯❯ Canine Thoracolumbar Intervertebral ❯❯ Pekinese With Acute Onset of Collapse
VIDEOS Disk Disease: Pathophysiology,
Neurologic Examination, and
Emergency Medical Therapy
❯❯ John F. Griffin IV, Jonathan M. Levine,
and Sharon C. Kerwin
Thoracolumbar intervertebral disk disease (IVDD)
is a common, important cause of paraspinal
hyperesthesia, pelvic limb ataxia, paraparesis, NEWS BITES
paraplegia, and urinary and fecal incontinence
❯❯ Laparoscopic in dogs. Recent research offers new insights into ❯❯ Vet Study Finds Aggressive Owners
Gastropexy the pathophysiology, diagnosis, prognosis, and Have Aggressive Dogs
Three videos show some treatment of this disorder. The comparative efficacy A University of Pennsylvania study has found that
aspects of the techniques of many familiar therapies remains unknown and most aggressive dogs will remain aggressive when
described in the February controversial. This article reviews the pathophysi- dog owners use confrontational or aversive methods
2009 Surgical Views
ology and epidemiology of this condition and the to try to train their pets.
column, “Laparoscopic-
examination and emergency medical therapy of
Assisted and Laparoscopic
dogs with suspected thoracolumbar IVDD. ❯❯ Economy Means Slowdown for Some
Prophylactic Gastropexy: Vet Practices
Indications and Techniques.” ❯❯ Canine Thoracolumbar Intervertebral A number of small animal practices have reported a
Disk Disease: Diagnosis, Prognosis, drop in client visits.
and Treatment
❯❯ New SPCA Vet Hospital a San
❯❯ John F. Griffin IV, Jonathan M. Levine, Francisco Treat
Sharon C. Kerwin, and Robert C. Cole
The $29-million Leanne B. Roberts Animal Care
Thoracolumbar intervertebral disk disease Center is the new home of the San Francisco SPCA’s
(IVDD) is a common, important cause of nonprofit veterinary hospital, spay/neuter clinic, and
paraspinal hyperesthesia, pelvic limb ataxia, shelter medicine program.
paraparesis, paraplegia, and urinary and fecal
incontinence in dogs. This article addresses the ❯❯ Beware of Cocoa Mulch
diagnosis, prognosis, and treatment of dogs with A popular option for landscaping, cocoa mulch can
thoracolumbar IVDD. be deadly to pets.
E-NEWSLETTER
❯❯ COMPENDIUM EXTRA Our
monthly e-newsletter provides
Web Exclusive articles and
news, as well as a preview of
this month’s journal. Sign up at
CompendiumVet.com.
CONTACT US
❯❯ Email your questions,
suggestions, corrections,
or letters to the editor:
editor@CompendiumVet.com
100 CompendiumVet.com
7. The potential for an animal poison emergency
is always there, so we are too.
A pill bottle accidently knocked off a sink. Everyday things can quickly become a poison emergency for a
pet. It’s the reason the ASPCA® Animal Poison Control Center is here 24/7/365 to support you with critical
recommendations. As the only center in North America dedicated solely to animals, we have an experienced
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For information on our online Toxicology CE courses, visit www.apcc.aspca.org. *American Board of Veterinary Toxicology www.abvt.org
No animals were harmed during the production of this ad.
8. The Editor’s Desk
❯❯ Tracey L. Giannouris, MA, Executive Editor
Tracey with her son,
Michael Francis
Meet Our New Online CE “Sister”
F
or more than 30 years, Compendium has 145,000 registered users (43.3% of whom are
been your trusted source for continuing practicing veterinarians; 47.7%, veterinary tech-
education (CE), both in print and, more nicians; 3%, veterinary technician students; and
recently, on the Internet. Now, all of us here 1.2%, veterinary students) visit VetLearn.com.
at Compendium are pleased to announce the While there, they investigate a total of 200,000
expansion of our CE efforts with the launch of a pages (40,000 of which are clinical CE review
new Web site: CECenter.com. articles) and obtain a total of 2,000 CE credits.
CECenter.com, a companion site to VetLearn. Based on these numbers, we saw a clear need to
com (which comprises CompendiumVet.com, expand our CE offerings by creating a compan-
CompendiumEquine.com, SOCNewsletter.com, ion portal dedicated to “all things CE.”
VetTechJournal.com, VeterinaryTherapeutics.com, CECenter.com gives both veterinarians and
and ForumVet.com), is devoted exclusively to provid- veterinar y technicians the ability to search
ing interactive online CE to veterinarians and veteri- for and participate in CE activities. In addition
nary technicians. The mission behind the site is to to the archive of our own peer-reviewed arti-
provide veterinary practitioners with new, timely cles, CECenter.com offers exclusive, interactive,
information that can be immediately incorporated sponsored courses accredited by the Registry
into practice. To achieve this goal, we have gathered of Approved Continuing Education, as well
in one central location a wide array of CE activities, as a complete list of CE requirements by state
from peer-reviewed CE content from Compendium, and links to CE programs from other respected
Compendium Equine, and Veterinary Technician to sources such as the AVMA, the American Animal
presentations given by recognized experts. Hospital Association, and accredited universities
Our realization of the need for a dedicated and institutions. Other features of CECenter.com
veterinary CE portal crystallized with our rec- include a preview of upcoming courses and activ-
ognition of the increasing number of veterinary ities. Users get individual accounts that contain a
practitioners who are using the VetLearn.com and permanent online record of their CE history and
CompendiumVet.com sites to meet CE require- allow them to reprint any CE certificate at any
ments. In an average month, approximately time. And our plans call for more CE offerings—
and more CE-related features and content—as
CECenter.com grows throughout 2009.
CECenter.com is accessible to everyone regis-
tered on VetLearn.com or CompendiumVet.com,
and registration is free. If you haven’t already
registered, we invite you to sign up now so
that you can explore CECenter—and our other
sites—for yourself. We are confident that, along
with CompendiumVet.com, CECenter.com will
become the preferred online CE source for you
and your technician staff.
As always, we welcome your feedback, comments,
and suggestions for both VetLearn.com and
CECenter.com. Please feel free to email me at
tgiannouris@vetlearn.com.
102 Compendium: Continuing Education for Veterinarians® | March 2009 | CompendiumVet.com
12. Disclosing Medical Errors: Restoring Client Trust
Joint Commission4 have clear statements that clude, and explain than the practice where the
require accurate disclosure of adverse medi- adverse event took place?
cal outcomes in human medicine. Similar ethi- Most client disappointments with veterinary
cal positions exist in veterinary medicine.5 outcomes are not the result of negligent care.
Research in human medicine and other pro- For instance, clients may have unreasonable
fessions6–10 has described the potential advan- expectations that were not adequately addressed
tages of a more open approach with patients, or corrected. They may not appreciate the vari-
families, and “customers” in these situations. ability between animals or that diagnostic and
When applied to veterinary medicine, these treatment plans are based on probabilities rather
benefits include the following: than certainties. The clinical picture may change
as additional signs emerge and the response to
More situations can be worked out directly treatment is assessed.15 Almost every effective
between the veterinarian, the client, and the treatment brings with it the potential for untow-
insurance carrier without stimulating legal ard side effects and complications. Unless clients
action or formal complaints to licensing boards. are apprised of these risks, they may mistakenly
The AVMA Professional Liability Insurance believe that similarly trained clinicians would
Trust (PLIT) recommends that veterinarians have been able to solve the problem more quickly,
call the PLIT office as soon as possible after an with less suffering, and at a lower cost. Each of
event that could give rise to a claim.b the above factors is a reminder of the importance
Rebuilding rapport and trust and resolving of obtaining true owner consent, recognizing
disagreements can turn initial client disap- and correcting unreasonable expectations, and
QuickNotes pointment into an even stronger relationship. offering adequate explanations when diagnosis
When the practice and the insurance carrier are and treatment are unsuccessful, even when the
Most client disap- willing to initiate discussion of fair settlements standard of care is met.16
pointments with with clients who have been legitimately affected
veterinary outcomes by errors in practice, the dollar amounts tend Errors and Harm in Veterinary Medicine
are not the result of to be easier to negotiate and more reasonable While research into the incidence, type, and
negligent care. than those obtained through legal action7,8,11 impact of errors in veterinary medicine is limited,
because client bitterness is minimized and dol- it is clear that adverse events related to errors do
lar amounts are focused on reasonable com- occur. For instance, one small UK study17 found
pensation rather than punishment. that 78% of recent practicing veterinary gradu-
ates surveyed reported they had made a mistake
Adverse Outcomes and Medical Errors that resulted in a less-than-optimal or potentially
Adverse outcome is the term used in veterinary adverse outcome for a patient. Most mistakes
and human medicine to indicate unanticipated involved failure to conduct appropriate diagnostic
harm that results from a medical treatment tests, surgical mistakes during procedures other
rather than from a disease or condition itself.12 than neutering, and administration of inappro-
An ethical approach to disclosure of harm priate drugs or medical treatment. Forty percent
hinges on the veterinarian’s commitment to reported that they had not discussed the error
determining and then sharing the most accurate with the client. These mistakes caused many of
conclusions about how the harm was caused. the respondents considerable distress.
While sometimes fairly clear, many situations
require the veterinarian to draw a bright line Disclosure and Resolution: A Protocol
through a gray situation to determine whether Research has consistently indicated that, in
a breach of the standard of care caused the human medicine, patients and families typically
harm (and, therefore, the harm was prevent- want to hear the following from the care provider
able) or whether the harm occurred in the con- when an adverse event or outcome occurs10,18–21:
text of care that most veterinarians would judge
as reasonable in a similar instance.13,14 Practically What happened
and emotionally, this can be difficult to do, yet How it happened
who is in a better position to investigate, con- What the immediate medical consequences
are, and what impact they will have on
b
Ellis LJ. Personal communication, AVMA PLIT, 2007. quality of life
106 Compendium: Continuing Education for Veterinarians® | March 2009 | CompendiumVet.com
15. 1
antidote
In a poison emergency,
trust ToxiBan. ®
There’s a reason ToxiBan has been the number one selling
poison treatment for more than 30 years. When it comes to
emergencies, trust your patients’ lives to the poison treatment
that has become the industry gold standard. Trust ToxiBan.
50+
• Recommended by the ASPCA Animal Poison Control Center
and many other organizations
• Three dosing options: granules, suspension and suspension
with sorbitol
• Sorbitol acts as a mild cathartic
poisons When your patients’ lives are in your hands,
make sure ToxiBan is on your shelf.
1,000,000+
animals
treated
16. Disclosing Medical Errors: Restoring Client Trust
the discussion, even if the adverse event was Elicit and acknowledge client reactions.
primarily caused by another staff member’s Frequently throughout the discussion, you
actions. The presence of a person who was should solicit the client’s perspective through
not directly involved with the adverse event questions and statements such as, “What
and who has credibility, maturity, and strong thoughts or questions do you have about
communication skills, such as the practice what I have explained so far?” and “I imag-
manager, can help facilitate and mediate what ine you have many emotions and questions,
can be a difficult conversation. Plan when and and I want to hear from you first before going
how to begin the discussion. An initial discus- on.” Eliciting reactions serves to validate the
sion with the client should take place as soon client’s perspective on the medical error and
as possible after the adverse event. adverse outcome and sets the stage for effec-
tive interaction.
Disclose to the client what occurred and Voice tone and body language are as
apologize. important as actual words in conveying empa-
Disclose what you know, but guard against thy for the client’s experience. Showing your
premature conjecture until you are as certain “human side” through genuine expressions of
as you can be about causes and consequences. empathy can strengthen the bond and trust
When possible, make an initial phone call to between you and your client. An empathetic
set up an in-person meeting rather than have veterinarian is not defensive, even when a cli-
the discussion over the phone. If a phone dis- ent expresses anger and makes accusations.
closure cannot be prevented, start the discus- Acknowledging the client’s reaction as a legiti-
sion by acknowledging how sorry you are to mate one by making a statement such as, “It is
QuickNotes have to be sharing the news over the phone. normal to feel shocked and angry to learn that
Disclose what you In person, start the discussion by offering a something like this has happened,” does not
know, but guard frame for the information to follow: indicate that you agree with the conclusions
against premature that prompted it.
conjecture until “I have some difficult news to share with
you. I’m very sorry to have to tell you…” Apologize appropriately.
you are as certain
After an adverse event or outcome, the proper
as you can be Then explain the situation by addressing type of apology can have a powerful effect
about causes and each of the issues listed above. BOX 2 offers on the client, making him or her less angry
consequences. some additional guidelines to approaching the and suspicious. There are two types of apol-
disclosure conversation. ogy: an apology of sympathy and an apology
of responsibility. An apology of sympathy
is:
BOX 2
Guidelines for Disclosure “I’m sorry this happened to you and your
pet.”
1. Choose a quiet place.
An apology of responsibility is:
2. Ensure that there will be no distractions
(e.g., turn cell phones and pagers off).
3. Provide a warning (e.g., “ I have difficult “I am terribly sorry for this error we made
news to share.”). that has caused more problems for your pet.”
4. Be attentive to your own and your client’s
nonverbal messages. Mazor and colleagues6,24 demonstrated that
❯ Make eye contact. in situations in which a breach of the standard
❯ Sit at the client’s level. of care caused harm, respondents reported
❯ Respond appropriately to client nonverbal more trust and satisfaction and less likelihood
cues (e.g., “I see that this is shocking to you. of changing doctors when they received full
Should I go on or do you need a moment?”). disclosure with an apology of responsibility.
5. Facilitate discussion and encourage questions. In instances in which an adverse event is not
6. Finish with a plan for the next contact. the result of medical error, an apology of sym-
pathy is appropriate.
110 Compendium: Continuing Education for Veterinarians® | March 2009 | CompendiumVet.com
17. Disclosing Medical Errors: Restoring Client Trust
Discuss the plan for care of the animal. come from the harm they have experienced.
In many instances, by the time the disclosure It is unacceptable to clients to think that a
conversation takes place, steps have already veterinarian’s failure to change or reflect on
been taken to care for the animal, and the the incident means that others are likely to
veterinarian is thinking about other poten- suffer similarly.23 These sentiments become
tial consequences of the error. However, it is expressed as complaints to licensing boards
important to remember that the client has just as well as malpractice suits. Therefore, the vet-
received the news. Discuss the recommended erinarian’s goal is to convey to the client that
plan for continuing care of the animal, includ- he or she has learned everything that can be
ing the potential short- and long-term out- learned from the adverse event:
comes. Often, clients are unclear about what
lasting effect the error will have on their pet “I can promise you that we’ll all be meeting
and may not comprehend the gravity or—in later today to review every step of our proce-
some cases—the limited impact of the error. It dures. We want to immediately change any-
is critical that immediate concerns as well as thing that makes it more likely that this could
the potential long-term impact be discussed in happen again to any other animal in our
a manner the client understands. care.”
Be accountable and offer reparation. Don’t rush.
Finally, the practice must acknowledge respon- Keep in mind that all these elements of dis-
sibility to help the client recover as much as closure may take more than one meeting or
possible from the harm that has been caused. conversation to deliver effectively to the client. QuickNotes
Appropriate fees for the animal’s care should Discussion of reparation may take the longest The heart of all
be waived. The veterinarian should anticipate to resolve in cases in which the impact of the effective and ethical
discussion of who will pay for follow-up care harm on the surviving animal and the extent
disclosure is to
before the disclosure conversation. Again, the of needed ongoing treatment are uncertain.
AVMA PLIT recommends that it be contacted However, if a client has suffered serious loss
provide the client
early on to discuss how best to approach this or even financial harm (e.g., economic impact with an accurate
situation. on a breeding kennel), he or she is going to understanding of
Being accountable and willing to make rep- want to promptly hear that you (with your what has happened.
arations is crucial in the disclosure process; liability carrier’s guidance) intend to offer fair
however, it does not mean immediately offer- compensation.
ing money. Rather, it means opening up the The heart of all effective and ethical disclo-
conversation: sure is to provide the client with an accurate
“Can we do more to resolve this with you? understanding of what has happened. The
We stand ready to do what we can to help you form an apology takes and the offers made to
recover from this as much as possible.” help a client recover from an injury caused by
According to the Sorry Works! Coalition,25 a medical error should flow naturally from the
leading advocacy organization for disclosure veterinarian’s own understanding of his or her
after adverse medical events, paying for errors degree of responsibility for the injury.
is the ethical thing to do. However, there may
be a fear that it will appear as if you are “buy- Summary
ing” clients off. This is an understandable con- Consider your recommendations to your
cern. In veterinary medicine, all of the steps nephew in the scenario at the start of this col-
of disclosure—admission of error, explanation, umn. Ask yourself the following questions: Are
apology—can still be delivered sincerely, and my recommendations based on ethical stan-
PLIT or your liability carrier can be consulted dards of openness, transparency, and integ-
on how to offer reparation. rity? Would I be satisfied if I were the client?
Despite our best efforts, animals will occasion-
Describe plans to fi x the behavior or sys- ally be harmed by problems that occur while
tem that contributed to the harm. they are in our or our staff’s care. Having a
Consumers who are affected by a medical standard approach to disclosure and resolu-
error want to know that something good has tion that is consistent with our values, despite
CompendiumVet.com | March 2009 | Compendium: Continuing Education for Veterinarians® 111