Compendium
                 CompendiumVet.com | Peer Reviewed | Listed in MEDLINE   Vol 31(3) March 2009




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THE PARTY’S OVER FOR                                                                                                      ...
March
                                                                                                     2009 Vol 31(3)
...
March
2009 Vol 31(3)
                                          CompendiumVet.com | Peer Reviewed | Listed in MEDLINE


   ...
E
        Each CE article is accredited for 3 contact hours by
 CE     A
        Auburn University College of Veterinary M...
March
2009 Vol 31(3)                                                                                         WEB EXCLUSIVE...
The potential for an animal poison emergency
             is always there, so we are too.
A pill bottle accidently knocked...
The Editor’s Desk
                        ❯❯ Tracey L. Giannouris, MA, Executive Editor




Tracey with her son,
Michael F...
LETYOUR
                LET YOUR
              SCIENCE
           CONSCIENCE
               GUIDE
                YOU.

  ...
Clinical Snapshot
 Particularly intriguing or difficult cases

Case Presentation #1                                        ...
©2009 Monkey Business Images/Shutterstock.com
Disclosing Medical Errors:
                      *
Restoring Client Trust
❯❯...
Disclosing Medical Errors: Restoring Client Trust

                            Joint Commission4 have clear statements tha...
®
Disclosing Medical Errors: Restoring Client Trust

                                                                       ...
1
  antidote
             In a poison emergency,
             trust ToxiBan.                        ®




             The...
Disclosing Medical Errors: Restoring Client Trust

                            the discussion, even if the adverse event w...
Disclosing Medical Errors: Restoring Client Trust

Discuss the plan for care of the animal.            come from the harm ...
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  1. 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 ® FREE CE Vomiting Treatment Options Understanding Behavior Stress-Induced Hypersensitivity in Cats FREE CE Squamous Cell Carcinoma t : us rs e 1 nt E t n 05 Tr rro e P Cl ic me Se ng ed ge ag ie al a or M an st ing e M Re los ctic sc Pra i Di
  2. 2. THE PARTY’S OVER FOR AP N TO KIL LD P OW EM R FLEAS AND TICKS. OD O EX MI VE TE SO D N DO ProMeris . The next generation of flea and tick control. ® GS EFFECTIVE CHEMISTRY FLEA & TIC Mode of action provides effective PROTECTIO EFFECTIVE CHEMISTRY and long-lasting control of fleas. Kills fleas and ticks on Mode of action provides effective Kills fleas on cats. and long-lasting control of fleas. LONG LASTING Controls fleas for up to six weeks and ticks fo LONG LASTINGto four weeks on dogs. Controls fleas for up to Controls fleas for up to six weeks and ticks foron cats. Fits easily into a monthly regim weeks up to four weeks on dogs. Controls fleas for up to seven weeks on cats. Fits easily into a monthly regimen. FLEA & TICK FLEA & TICK PROTECTION PROTECTION EASY TO USE EFFECTIVE CHEMISTRY EFFECTIVE CHEMISTRY Kills fleas and ticks on dogs. Kills fleas and ticks on dogs. Non-drip applicator design makes treatment a snap. Mode of action provides effective Kills fleas on cats. Kills fleas on cats. Mode of action provides effective and long-lasting control of fleas. and long-lasting control of fleas. LONG LASTING LONG LASTING GENTLE GENTLE Controls fleas for up to six weeks and ticks for up Controls fleas for up to six weeks and ticks for up Formulated for dogs and puppies Formulated for dogsKeeps wo and pupp to four weeks on dogs. Controls fleas for up to seven weeks on dogs. Controls fleas for up to seven to four 8 weeks and older and cats and 8 weeks and older and cats a weeks on cats. Fits easily into a monthly regimen. weeks on cats. Fits easily into a monthly regimen. kittens 8 weeks and older. kittens 8 weeks and older. FLEA & TICK FLEA & TICK PROTECTION EASY TO USE EASY TO USE PROTECTION EFFECTIVE CHEMISTRY TIVE CHEMISTRY of action provides effective Kills fleas and ticks on dogs. Kills fleas and ticks on dogs. Non-drip applicator design Non-drip applicator design makes treatment a snap. Mode Kills fleas on cats. makes treatment a snap. of action provides effective Kills fleas on cats. and long-lasting control of fleas. ng-lasting control of fleas. LONG LASTING LONG LASTING GENTLE GENTLE WATERPROOF WATERPROOF Controls fleas for up to six weeks and ticks for up Formulated for dogs and puppies Keeps working on dogs even after swimming. Controls fleas for up to six weeks and ticks for up Formulated for dogs and puppies Keeps working on dogs even after swimming. to four weeks on dogs. Controls fleas for up to seven 8 weeks and older and cats and to four weeks on dogs. Controls fleas for up to seven 8 weeks and older and cats and weeks on cats. Fits easily into a monthly regimen. kittens 8 weeks and older. weeks on cats. Fits easily into a monthly regimen. kittens 8 weeks and older. Discover the difference. ProMeris: • Metaflumizone – no other flea control product utilizes this active ingredient • Metaflumizone kills fleas by targeting voltage-dependent sodium channels along presynaptic and postsynaptic nerves resulting in paralysis and death • Convenient topical application • Features first topical formulation of amitraz for well-recognized and proven tick control on dogs Dosing Convenience: • Five sizes for dogs and two sizes for cats with three- or six-dose packs for monthly application Discover the difference ProMeris offers you and your patients. Contact your ProMeris distributor, visit www.ProMeris.com or call 1-888-PROMERIS today. Available from the following authorized veterinary distributors: DVM Resources • Great Western Animal Health Supply • Henry Schein Animal Health • IVESCO • Midwest Vet Supply • NLS Animal Health Nelson Laboratories • Penn Vet Supply • PCI Animal Health • VetSource • Vet Pharm • Victor Medical Company • Webster Vet Supply ProMeris is a registered trademark of Wyeth. ©2008 Fort Dodge Animal Health, a division of Wyeth.
  3. 3. March 2009 Vol 31(3) CompendiumVet.com | Peer Reviewed | Listed in MEDLINE EXECUTIVE EDITOR Tracey L. Giannouris, MA 800-426-9119, ext 52447 | tgiannouris@vetlearn.com MANAGING EDITOR Kirk McKay 800-426-9119, ext 52434 | kmckay@vetlearn.com Subscription inquiries: PUBLISHED BY SENIOR EDITOR 800-426-9119, option 2. Robin A. Henry Subscription rate: $79 for 1 year; $143 for 2 years; $217 800-426-9119, ext 52412 | rhenry@vetlearn.com for 3 years. Canadian and Mexican subscriptions (sur- ASSOCIATE EDITOR face mail): $95 for 1 year; Chris Reilly $169 for 2 years; $270 for 3 800-426-9119, ext 52483 | creilly@vetlearn.com years. Foreign subscriptions (surface mail): $175 for 1 EDITORIAL ASSISTANT Published monthly by Veteri- year; $275 for 2 years; $425 Benjamin Hollis nary Learning Systems, a for 3 years. Payments by 800-426-9119, ext 52489 | bhollis@vetlearn.com division of MediMedia, check must be in U.S. funds 780 Township Line Road, drawn on a U.S. branch of a VETERINARY ADVISER Yardley, PA 19067. Copyright U.S. bank only; credit cards Dorothy Normile, VMD, Chief Medical Officer © 2009 Veterinary Learning are also accepted. Change 800-426-9119, ext 52442 | dnormile@vetlearn.com Systems. All rights reserved. of Address: Please notify Printed in the USA. No part of the Circulation Department SENIOR ART DIRECTOR this issue may be reproduced 45 days before the change in any form by any means Michelle Taylor is to be effective. Send your without prior written permis- 267-685-2474 | mtaylor@vetlearn.com new address and enclose an sion of the publisher. address label from a recent ART DIRECTOR issue. Selected back issues Printed on acid-free paper, David Beagin effective with volume 29, are available for $15 (United 267-685-2461 | dbeagin@vetlearn.com issue 5, 2007. States and Canada) and $17 (foreign) each (plus postage). OPERATIONS Periodicals postage paid at Marissa DiCindio, Director of Operations Morrisville, PA, and at addi- Indexing: Compendium: Con- tinuing Education for Veteri- 267-685-2405 | mdicindio@vetlearn.com tional mailing offices. narians® is included in the Elizabeth Ward, Associate Production Manager–Journals Postmaster: Send address international indexing cover- age of Current Contents/ 267-685-2458 | eward@vetlearn.com changes to Compendium: Agriculture, Biology and Continuing Education for Environmental Sciences (ISI); SALES & MARKETING Veterinarians®, 780 Township SciSearch (ISI); Research Joanne Carson, National Account Manager Line Road, Yardley, PA 19067. Alert (ISI); Focus On: Veteri- 267-685-2410 | Cell 609-238-6147 | jcarson@vetlearn.com Canada Post international nary Science and Medicine publications mail product (ISI); Index Veterinarius Boyd Shearon, Account Manager (Canadian distribution) sales (CAB International, CAB 913-322-1643 | Cell 215-287-7871 | bshearon@vetlearn.com agreement no. 40014103. Abstracts, CAB Health); and Return undeliverable Canadian Agricola (Library of Congress). Lisa Siebert, Account Manager addresses to MediMedia, Article retrieval systems 913-422-3974 | Cell 215-589-9457 | lsiebert@vetlearn.com PO Box 7224, Windsor, ON include The Genuine Article N9A 0B1. Printed in USA. (ISI), The Copyright Clear- CLASSIFIED ADVERTISING ance Center, Inc., University Liese Dixon, Classified Advertising Specialist Compendium: Continuing Education for Veterinarians® Microfilms International, and 800-920-1695 | classifieds@vetlearn.com | www.vetclassifieds.com Source One (Knight-Ridder (ISSN 1940-8307) Information, Inc.). Yearly EXECUTIVE OFFICER author and subject indexes Derrick Kraemer, President for Compendium are pub- lished each December. CUSTOMER SERVICE 800-426-9119, option 2 | info.vls@medimedia.com CompendiumVet.com 97
  4. 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
  5. 5. E Each CE article is accredited for 3 contact hours by CE A Auburn University College of Veterinary Medicine. March 2009 Vol 31(3) Features CompendiumVet.com | Peer Reviewed | Listed in MEDLINE 105 Disclosing Medical Errors: Restoring Client Trust ❯❯ Kathleen A. Bonvicini, Daniel O’Connell, and Karen K. Cornell Discussing medical errors with affected clients can ultimately benefit your practice. This article provides tips on creating a protocol for resolving medical errors. 122 Vomiting FREE ❯❯ Héctor J. Encarnación, Joshua Parra, Erick Mears, and Valerie Sadler CE Antiemetic drugs act by affecting neurotrans- mitter–receptor interactions in many areas of the body. Learn why different drugs are used for different causes of vomiting. 133 Squamous Cell Carcinoma FREE ❯❯ Julie L. Webb, Rachel E. Burns, CE Holly M. Brown, Bruce E. LeRoy, and C i E K d Carrie E. Kosarek The authors review the causes, diagnosis, and treatment of this tumor type. Departments Cover image © 2009 Michael Woodruff/Shutterstock.com 100 CompendiumVet.com 102 The Editor’s Desk: Meet Our New Online Understanding Behavior CE “Sister” 116 Feline Hyperesthesia Syndrome ❯❯ Tracey L. Giannouris ❯❯ John Ciribassi 104 Clinical Snapshot The etiology of feline hyperesthesia Pruritus in a Great Dane syndrome can be difficult to determine. ❯❯ Karen A. Moriello Behavior modification and medications 113 Letters may help in treatment. 132 Product Forum Clinical Snapshot 143 Index to Advertisers PAGE 104 143 Market Showcase 143 Classified Advertising Compendium: Continuing Education for Veterinarians® 99
  6. 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. 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 team of board certified veterinary toxicologists* on staff with the special expertise needed to save a pet’s life. Our exclusive AnTox™database of more than one million cases of animal poisonings also gives us immediate access to crucial case information. When potential danger turns into a real emergency, don’t hesitate. Call us. ORDER A FREE MAGNET Visit www.aspca.org/freemagnet for your free ASPCA Animal Poison Control Center magnet − an easy way to keep our emergency number handy. 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. 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
  9. 9. LETYOUR LET YOUR SCIENCE CONSCIENCE GUIDE YOU. Milbemycin oxime is trusted #1 by veterinarians for use on their own dogs.1 Veterinarians also believe that INTERCEPTOR® (milbemycin oxime) Flavor Tabs® provide better science and value for the money than Heartgard.2 Dogs and Cats should be tested for heartworm prior to use. In a small percentage of treated dogs, digestive and neurologic side effects may occur. In cats, safety studies at up to 10 times the label dose did not detect any adverse drug reactions. Please see brief summary on page XX for more information. 104 for more information. 1 Milbemycin oxime. Parasiticide Usage Study, June 2005. Data on file. Novartis Animal Health US, Inc. 2 Data on file. Novartis Animal Health US, Inc. ©2009 Novartis Animal Health US, Inc. INTERCEPTOR and Flavor Tabs are registered trademarks of Novartis AG. Heartgard is a registered trademark of Merial Ltd.
  10. 10. Clinical Snapshot Particularly intriguing or difficult cases Case Presentation #1 TO LEARN MORE ❯❯ Karen A. Moriello, DVM, DACVD, University of Wisconsin-Madison This Great Dane (A) was one of 12 border collies and seven cats in addi- Clinical Snapshot presents illustrated dogs in a kennel, all of which had had tion to these dogs. What are the treat- case histories and challenges you to intense pruritus for 1 year. The owners ment options for this kennel of dogs? answer the questions posed. This case reported that the other dogs looked 3. A similarly named condition occurs is part of the series of Self-Assessment similar and that all the dogs were los- in cats. What is the cause, and what Colour Review books on multiple topics ing weight and were irritable with the treatment can be used for this from Manson Publishing Ltd., London, available from Blackwell Publishing owners and each other. Close examina- condition? Professional. tion of the skin revealed a generalized SEE PAGE 114 FOR ANSWERS AND EXPLANATIONS. papular eruption without evidence of For more information or to obtain any of the pustules or epidermal collarettes. Any A books in the series, call 800-862-6657 manipulation of the skin triggered an or visit BlackwellProfessional.com intense episode of self-mutilation. All the dogs were currently vaccinated and B received monthly heartworm medica- tion and monthly spot-on flea control. The owners reported no lesions or dis- comfort after handling the dogs. Flea combings were negative. Skin scrap- ings revealed the organism shown (B). 1. What is the diagnosis? 2. The owners of the kennel have three INTERCEPTOR Flavor Tabs are palatable and most often will be consumed by the dog or cat when offered by the owner. As an alternative, the dual-purpose tablet may be offered in food or administered as other tablet medications. Watch the dog or cat closely following dosing to be sure the entire dose has been consumed. If it is not entirely consumed, redose once with the full recommended dose as soon as possible. INTERCEPTOR Flavor Tabs must be administered monthly, preferably on the same date each month. The first dose should be administered within one month of the dog or cat’s first exposure to mosquitoes and monthly thereafter until the end of the mosquito season. If a dose is missed and a 30-day interval between dosing is exceeded, administer INTERCEPTOR Flavor NADA 140-915, Approved by FDA Tabs immediately and resume the monthly dosing schedule. INTERCEPTOR® (milbemycin oxime) Flavor Tabs® for Dogs and Cats If INTERCEPTOR Flavor Tabs replace diethylcarbamazine (DEC) for heartworm prevention in dogs, the first dose must be Brief Summary—For full product information see product insert. given within 30 days after the last dose of DEC. Caution: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. Warnings: Not for human use. Keep this and all drugs out of the reach of children. Indications and Usage: INTERCEPTOR Flavor Tabs for dogs are indicated for use in the prevention of heartworm disease Precautions: caused by Dirofilaria immitis, the control of adult Ancylostoma caninum (hookworm), and the removal and control of adult Dogs: Do not use in puppies less than four weeks of age and less than two pounds of body weight. Prior to initiation of the Toxocara canis and Toxascaris leonina (roundworms) and Trichuris vulpis (whipworm) infections in dogs and in puppies INTERCEPTOR Flavor Tabs treatment program, dogs should be tested for existing heartworm infections. Infected dogs four weeks of age or greater and two pounds body weight or greater. INTERCEPTOR Flavor Tabs are indicated for use should be treated to remove adult heartworms and microfilariae prior to initiating treatment with INTERCEPTOR Flavor Tabs. in the prevention of heartworm disease caused by Dirofilaria immitis, and the removal of adult Ancylostoma tubaeforme Mild, transient hypersensitivity reactions manifested as labored respiration, vomiting, salivation, and lethargy may occur (hookworm) and Toxocara cati (roundworm) in cats and kittens six weeks of age or greater and 1.5 lbs. body weight or after treatment of dogs carrying a high number of circulating microfilariae. greater. Cats: Do not use in kittens less than six weeks of age or less than 1.5 lbs. body weight. Safety in heartworm positive cats has Dosage and Administration: not been established. Safety in breeding, pregnant, and lactating queens and breeding toms has not been established. Dogs: INTERCEPTOR Flavor Tabs for Dogs are given orally, once a month, at the recommended minimum dosage rate of 0.23 mg milbemycin oxime per pound of body weight (0.5 mg/kg). Adverse Reactions: The following adverse reactions have been reported following the use of INTERCEPTOR in dogs: depression/lethargy, vomiting, ataxia, anorexia, diarrhea, convulsions, weakness, and hypersalivation. Recommended Dosage Schedule for Dogs Body Weight INTERCEPTOR Flavor Tabs Efficacy: 2–10 lbs. One tablet (2.3 mg) Dogs: INTERCEPTOR Flavor Tabs eliminate the tissue stage of heartworm larvae and the adult stage of hookworm 11–25 lbs. One tablet (5.75 mg) ( Ancylostoma caninum), roundworms ( Toxocara canis, Toxascaris leonina ), and whipworm ( Trichuris vulpis) infestations 26–50 lbs. One tablet (11.5 mg) when administered orally according to the recommended dosage schedule. 51–100 lbs. One tablet (23.0 mg) Cats: INTERCEPTOR Flavor Tabs for Cats eliminate the tissue stage of heartworm larvae and hookworm (Ancylostoma Dogs over 100 lbs. are provided the appropriate combination of tablets. tubaeforme ) and roundworm ( Toxocara cati ) infections when administered orally according to the recommended dosage schedule. Cats: INTERCEPTOR Flavor Tabs for Cats are given orally, once a month, at the recommended minimum dosage rate of 0.9 mg milbemycin oxime per pound of body weight (2.0 mg/kg). For technical assistance or to report suspected adverse events, call 1-800-332-2761. Recommended Dosage Schedule for Cats Manufactured for: Novartis Animal Health US, Inc. Body Weight INTERCEPTOR Flavor Tabs Greensboro, NC 27408, USA 1.5–6 lbs. One tablet (5.75 mg) ©2008 Novartis Animal Health US, Inc. 6.1–12 lbs. One tablet (11.5 mg) 12.1–25 lbs. One tablet (23.0 mg) INTERCEPTOR and Flavor Tabs are registered trademarks of Novartis AG. Cats over 25 lbs. are provided the appropriate combination of tablets. NAH/INT-FT/BS/5 06/08 104 Compendium: Continuing Education for Veterinarians® | March 2009 | CompendiumVet.com
  11. 11. ©2009 Monkey Business Images/Shutterstock.com Disclosing Medical Errors: * Restoring Client Trust ❯❯ Kathleen A. Bonvicini, T he purpose of this article is to help Your nephew says, “I feel terrible—what EdD, MPHa veterinarians reach a mutually satis- should I tell my clients?” Institute for Healthcare fying resolution with clients when Communication individual, team, or system errors result in How would you respond? What one New Haven, Connecticut an adverse outcome. It offers a model that piece of advice would you give to your integrates the ethics of veterinary medi- nephew? ❯❯ Daniel O’Connell, PhDa Institute for Healthcare cine with specific skills and attitudes that Communication have been shown to promote psychologic Ethics, Values, and Moral Compass Seattle, Washington and practical resolution of these situations In examining this scenario and consid- for clients and veterinary practices. ering your own opinions, you are likely ❯❯ Karen K. Cornell, DVM, relying on the values that guide the way PhD, DACVS Case Scenario you practice veterinary medicine. Still, this The University of Georgia Consider the following1: will be a very tough conversation to have. Athens, Georgia Many clinicians report feelings of shame, Your nephew, a recent veterinary school heartbreak, and vulnerability in situations graduate who is newly employed at a pri- like this one. Our natural instinct for self- vate small animal hospital, calls you for preservation, coupled with advice we may advice. Four days ago, he admitted a dog have received previously, can tempt us to At a Glance to the hospital for vaccinations and board- be very guarded when talking with clients Case Scenario ing. During the admission process, he about adverse outcomes and to use cal- Page 105 administered a Bordetella bronchiseptica culated omissions and rationalizations to Ethics, Values, vaccine to the dog. The dog died this morn- conceal evidence of an error. In the above and Moral Compass ing. In retrospect, your nephew realizes scenario, one might argue that vaccination Page 105 that he picked up a syringe of intranasal has inherent risks. A frightened young vet- Disclosure and Resolution: B. bronchiseptica vaccine that still had a erinarian might be attracted to such seduc- A Protocol needle on it from being drawn from the tive reasoning as, “Disclosing the actual Page 106 vial, then gave the vaccine subcutaneously. cause of death will increase the clients’ dis- This inappropriate route of administration tress and certainly will not bring back the What to Do When resulted in the development of liver failure animal. What good could come from tell- an Error Occurs Page 108 while the dog was boarded at the hospital. ing the clients what really happened?” Guidelines for Disclosure *Adapted with permission from Compendium Page 110 Rationale for Openness Equine 2008;3(1):14-22. a The ethical positions of organizations such Establish Practice Protocol Drs. Bonvicini and O’Connell disclose that their nonprofit foundation receives funding as the American Medical Association,2 the Page 112 from Bayer Animal Health. American College of Physicians,3 and the CompendiumVet.com | March 2009 | Compendium: Continuing Education for Veterinarians® 105
  12. 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
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  14. 14. Disclosing Medical Errors: Restoring Client Trust What can be done now and heartbreak for the patient’s and client’s How the problem will be prevented in the situation may leap to self-blame too quickly, future (i.e., the promise that something good only to have the investigation determine that will come from the adverse event) no deviation from the standard of care was An apology if appropriate (if errors led to implicated in the outcome. There is usually the harm) enough time to consult with a trusted col- league to clarify your thinking and reestablish The following protocol (summarized in BOX 1) your emotional equilibrium before needing to provides specific approaches to assist you in make a full explanation to a client about how organizing a thorough, appropriate, construc- an adverse outcome arose. tive response that meets the needs of the patient and the expectations of clients and Investigate the details of the event. that restores clients’ trust, regardless of the Develop clarity about what happened. The severity of the adverse event. client is entitled to the most accurate under- standing of what happened, which may take Tend to the patient’s immediate clinical some time and investigation to clarify. You care. can ask for the client’s patience while you In the event of an adverse outcome, the pri- investigate. Make—and keep—a clear prom- mary responsibility of the veterinarian is to ise to discuss the conclusions when they are address the needs of the patient and, if appro- reached. In many cases, the cause of the harm priate, obtain medical consultation or arrange is never fully determined; however, it remains for necessary follow-up. Consider that charges the veterinarian’s responsibility to disclose QuickNotes for services in these circumstances may not the most likely causal pathway. Determining Emotional self- be billable if they are addressing conditions whether error was the cause of harm should awareness is key caused by errors (including equipment fail- be guided by asking,22 “What would have been to adopting the most ures and system or procedural mistakes that expected of a similarly trained individual in constructive attitude caused harm). that situation?” and behavior. Address your own emotions and needs. Prepare for discussion with the client. Emotional self-awareness is key to adopting Start by trying to imagine and anticipate what the most constructive attitude and behavior. A the client may be thinking and feeling when clinician who is flooded with worries about hearing the news. O’Connell and Reifsteck23 potential complaints and possible malpractice suggest asking yourself the following self- suits may be unconsciously pushed to mini- reflection questions to help guide you in your mize or even distort the facts and explana- discussion with the client: tion offered to the client. On the other hand, the clinician who is overwhelmed with guilt What is the most accurate explanation for the BOX 1 adverse event? How would I want the situation to be han- What to Do When an Error Occurs dled if I were in the client’s position? 1. Care for the patient. How would I feel if I suspected or later learned that the provider had not been forthright with 2. Compose yourself and investigate the ©2009 Phase4Photography/Shutterstock.com details of the event. me about the injury and its causes? 3. Disclose to the client what occurred and It is helpful to rehearse the actual words you apologize, if appropriate. will use in explaining the adverse event because 4. Discuss with the client the hearing them will help you determine whether plan of care for the animal. they are likely to be adequate to address the cli- 5. Be accountable and discuss ent’s expected thoughts and feelings. methods of reparation. Consider carefully who should attend the 6. Share how you plan to disclosure conversation. The veterinarian who keep this from happening is primarily responsible for the care of the in the future. animal should be there and take the lead in 108 Compendium: Continuing Education for Veterinarians® | March 2009 | CompendiumVet.com
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  16. 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. 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

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