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The following is my assessment of the clinical events surrounding the case of ***, a 4-year and ***, an Emotional Support Animal belonging to ***. The acts evaluated in the present document took place from *** until ***2022, within ***.
The acts, together with the procedures and administered treatments as performed by ***, and actions that have contributed to or might have caused ***’s death, are explained in detail below:
As stated by the owner and observed in medical files, *** was previously diagnosed with a torn cranial cruciate ligament (ligaments of the knee joint) within ***.
For this condition, on October 21, 2022, the attending veterinary doctor within *** prescribed a non-steroidal anti-inflammatory drug, more specifically, Carprofen 100mg, two tabs per day, for 14 days. It is essential to mention that the owner was not provided with a Client Information Sheet explaining the side effects often associated with nonsteroidal anti-inflammatory drugs and did not inform the owner that ***’s caregiver should cease the treatment in case of adverse reactions.
Some of Carprofen’s most severe side effects include gastrointestinal disturbances, bleeding, and ulcerations. As stated by specialty literature and product insert, Carprofen should be ceased immediately in case these clinical signs occur. Also, Carprofen should not be administered in dehydrated, hypovolemic (low circulating blood volume), hypotensive dogs, or those with gastrointestinal disease or blood clotting abnormalities.
On ***, 2022, *** was taken to the previously mentioned boarding facility by her owner to be accommodated for a period of ten days. At admission, the owner instructed the staff of *** that *** should receive the treatment prescribed by the veterinary doctor working with ***.
On the evening of November 12, while in the boarding facility, *** started showing evident clinical signs of gastrointestinal ulceration or perforation. These clinical signs included vomiting of dark brown gastric contents and diarrhea. The boarding facility was unaware that ***’s clinical manifestations were secondary to the administered treatment and, unfortunately, kept administering Carprofen. It is without a doubt that continuing the treatment with the specified non-steroidal anti-inflammatory drug contributed to the rapid aggravation of ***’s condition and her sudden passing.
On the same evening of November 12, 2022, the boarding facility tried to help *** by giving her an injection of an antacid drug (famotidine, unknown dosage) and antidiarrheal drug (Imodium, unknown dosage), administered by mouth. However, her condition was extremely severe, and she did not respond to the treatment. It is essential to mention that the boarding facility staff within the canine resort does not have medical training, they are not veterinary doctors or technicians, and the owner did not consent to the administered treatment.
On November 13 at around 11:29 am, more than 12 hours after the occurrence of the first clinical signs, *** was taken to an Emergency Veterinary Care facility, more specifically, ***.
While in the hospital, *** underwent clinical and physical evaluation and a series of medical investigations, which included a complete blood count, packed cell volume (PCV, which measures the proportion of red blood cells in a given blood sample), blood biochemistry, thorax and abdomen radiographs and blood gas measurements. The result interpretation concluded that *** developed aspiration pneumonia which, more probably than not, occurred as a result of profuse vomiting.
Aspiration pneumonia is an infectious bacterial pulmonary process that occurs after the abnormal entry and passing through the larynx, trachea, and lung of oral or upper gastrointestinal tract content.
As described by specialty literature, aspiration pneumonia develops in three stages:
1. The first stage
This phase occurs immediately after aspiration and consists of damage to the airways and pulmonary tissue (parenchyma) as a direct result of the nature of the aspirated fluid (i.e., irritant or acidic). This caustic tissue damage triggers the activation
of key modulators of inflammation (cytokines) and other inflammatory mediators. The inflammation leads to cell death/necrosis (type I alveolar cells), bronchiolar (smaller branches of the bronchial tree) constriction, pulmonary hemorrhage, increased mucus production, increased vascular permeability resulting in extravasation of proteins into the pulmonary parenchyma, and pulmonary edema, alveolar (air sacs at the end of the bronchial tree) and lung collapse (atelectasis).
2. The second phase of aspiration pneumonia
This phase begins 4 to 6 hours after aspiration and lasts 12 to 48 hours. The second phase is characterized by the infiltration of white blood cells that fight infections (neutrophils) into the alveoli/air sacs and tissue area in and around the wall of the air sacs (pulmonary interstitium). This inflammatory phase consists of ongoing vascular leakage of proteins with the continued development of high-protein pulmonary edema, neutrophil sequestration and activation, and the release of further proinflammatory modulators. These first two stages constitute aspiration pneumonitis, characterized by inflammation without the secondary development of bacterial infection.
3. The third phase of aspiration pneumonia
This phase involves bacterial growth within the airways and pulmonary parenchyma and infection leading to actual pneumonia. In pneumonia, the standard diagnosis protocol requires the following:
Further, standard treatment protocol requires:
With a diagnosis established in due time, the correct treatment and supportive care, patients diagnosed with aspiration pneumonia have a fair to good prognosis with a survival rate of 77% to 82%.
Other diagnoses and conditions included on ***’s problem list as established within *** included:
The administered treatment while in the Emergency Care facility included:
On November 15, 2022, at around 3 pm, ***’s temperature rose to 106.1°F (reference range 101.0 to 102.5F°), and she went into cardiac arrest. The owner chose not to resuscitate *** and let her pass. *** was not submitted for a necropsy/autopsy
examination and was cremated as the attending veterinary doctor at *** recommended.
It is my opinion that with early intervention and a different approach to the case, *** might have had a chance to recover fully.
I, ***, DVM, state that there exists a reasonable probability that the care, skill, or knowledge exercised in the treatment, practice, or work that is the subject of the complaint fell outside acceptable professional standards and that such conduct was cause in bringing about the harm. I also find there to be negligence in failing to disclose known risks fully, complications, and alternatives to the surgery, treatment, and medications.
Considering the acts of negligence described in the present letter, I believe that *** should receive damages for emotional losses and reimbursement for the entire veterinary expenses. This opinion is subject to modification if additional information is provided and only for the sole use of the party requesting the opinion. This letter is not for publication without the express permission of the undersigned.
Sincerely,
***
I have reviewed the provided records of ***, a 6 year old Hound Mix belonging to Ms. ***.
Based on my 13 years of experience as a veterinary, it is my opinion that Dr. ***, the veterinarian who provided care for *** failed to practice medicine with that level of care, skill and treatment for the following reasons:
*** was diagnosed with chronic kidney disease (CKD) on 09/16/2020. His blood urea nitrogen and creatinine values were above the normal physiological limits as follows: BUN = 139 (reference range: 6-31 mg/dL) CREA = 13.1 (reference range: 0.5-1.6 mg/dL)
For two years, with the help of treatment and Mrs. *** perseverance and love, *** started to feel better and his biochemical blood values improved:
90/21/2020 – CREA = 7.8 mg/dL; BUN = 90 mg/dL
09/23/2020 – CREA = 6.6 mg/dL; BUN = 129 mg/dL
09/26/2020 – CREA = 6.8 mg/dL; BUN = 113 mg/dL
10/5/2020 – CREA = 5.2 mg/dL; BUN = 44 mg/dL
10/27/2020 – CREA = 3.6 mg/dL; BUN = 49 mg/dL
01/02/2021 – CREA = 3.6 mg/dL; BUN = 47 mg/dL
07/02/2021 – CREA = 2.9 mg/dL; BUN = 35 mg/dL
One year after the last biochemical blood analysis, Dr. *** scheduled *** for teeth cleaning, which included general anesthesia.
Administration of general anesthesia can induce a reduction in renal blood flow in some patients. If a patient already has damaged kidneys (as is the case with ***), the renal function will be even more limited.
On 07/21/2022, the pre-operative/pre-anesthetic blood profile (PAP) analyses highlighted: CREA = 5.9 mg/dL; BUN = 83 mg/dL; GLI = 137 mg/dL.
Dr. *** failed to notify Mrs. *** about the values of the PAP test and performed the teeth cleaning under general anesthesia. Mrs. *** found out about the elevated blood test values by accident.
After the dental procedure, *** health began to deteriorate, and Ms. *** tried numerous times to speak with Dr. *** to examine *** and administer the proper treatment.
Ms. *** wanted to administer *** subcutaneous treatment (Ringer lactate) as she did in the past to help him lower those high numbers but Dr. Dick didn’t call back.
Ten days after the teeth cleaning (01/08/2022), ***’s BUN and CREA values were 169 mg/dL and 15.6 mg/dL, respectively (three times higher than at the time of the dental procedure). On 08/03/2022, the values of BUN and CREA were even higher: 180 mg/dL and 20 mg/dL, respectively.
It should be noted that *** was diagnosed with CKD and had his teeth cleaned at the same hospital, ***.
On 07/08/2022, Ms. *** arrived with *** in an emergency at another veterinary practice ***. Following the examination and laboratory tests, the following were concluded by the ER doctor: renal failure, uremic syndrome, metabolic acidosis, anemia, heart murmur, hypertension, and lymphadenopathy.
The values of creatinine and blood urea nitrogen were: CREA = 20.6 mg/dl, BUN = 176 mg/dL, values that put his life in danger.
With treatment, ***’s condition started to improve, and on 08/10/2022, Mrs. *** even managed to take him out for short walks.
Unfortunately, in two days (10/08/2022), ***’s health declined rapidly, and Ms. *** had to euthanize her dog about two weeks after the dental procedure.
From my point of view, the teeth cleaning procedure should not have been performed. The values of the renal parameters were not within normal physiological limits, but four times higher for creatinine and three times higher for blood urea nitrogen. Not to mention the fact that *** also had a two-year history of chronic kidney disease.
With ***’s health history, a procedure with general anesthesia should only have been performed as a last resort to try to save his life, not for a dental procedure.
Also, insisting on administering amoxicillin when the dog vomits several times after taking it is problematic; other treatments could have been tried. Like most antibiotics, amoxicillin can irritate the stomach. *** already had an irritated stomach due to high levels of blood urea nitrogen and creatinine, and amoxicillin took on an already irritated and empty stomach (as he wouldn’t eat), led to vomiting.
This opinion is subject to modification if additional information is provided and only for the sole use of the party requesting the opinion. This letter is not for publication without the express permission of the undersigned.
***, DVM
Re: *** and my assessment of veterinary medical practice below standard of care and negligence, as well as failure to maintain appropriate medical records.
To whom it may concern:
The following is my assessment of the sequence of clinical events, surrounding the tragic passing of ***, a previously deceased, 7-year-old, approximately 17-pound, male Dachshund, belonging to ***, and who passed from complications from gastrointestinal ulceration and perforation, which resulted in peritonitis, sepsis, and acute kidney failure. It is my STRONG professional opinion, based on 30 years of clinical veterinary experience, that *** was the victim of gross negligence and malpractice, involving inappropriate use of corticosteroids and non-steroidal anti-inflammatory drugs at the same time, as well as negligent medical practice at multiple points of treatment, leading up to the gastrointestinal perforation. There were also totally inadequate medical records on this case at several stages of treatment as well by the primary veterinary care hospital at ***.
In reviewing the quite minimal medical records supplied to me in this case, the evidence of negligent medical practices is obvious as early as June 18, 2019, when *** was treated with both a dexamethasone injection and Rimadyl injection for some sort of acute medical condition (no physical exam or SOAP notes provided by Veterinary Clinic). There is no justifiable and reasonable medical reason why any canine patient should receive treatment with both a strong corticosteroid such as Dexamethasone, and a non-steroidal drug like Rimadyl at the same time, especially with ***’s medical history. On this date, she was also sent home with generic Rimadyl (known as Vetprofen) tablets. I have no idea what *** was being treated for on June 18, 2019, as did not supply any medical records for this date. The concomitant use of both a corticosteroid and non-steroidal anti-inflammatory drug pose severe medical risks to the patient, including gastrointestinal erosion and ulceration, as well as significant immune suppression in any aged patient, even when used short term. This is even more inexcusable with ***’s medical history, as *** was suffering from a chronic autoimmune disease of her colon for 2.5 years, which had been diagnosed in 2017 at by endoscopic biopsy. According to ***, *** had been misdiagnosed and wrongly prescribed medications for “supposed pancreatitis” by at that time in 2017, with a 3-month history of severe, mucousy and bloody stools, which was not responding to treatment for pancreatitis. It was not until the correct diagnosis was made by *** and the appropriate, oral prednisone prescribed, that *** experienced clinical relief of this chronic and incurable autoimmune bowel condition. In fact, at the time of ***’s passing, she had still been on a low maintenance dose of prednisone to control this chronic bowel condition, and so the prescribing of Vetprofen on June 18, 2019, was an early sign of medical negligence and malpractice, given that *** was taking oral prednisone long term.
The next date of medical malpractice in this case is obvious on September 23, 2019. On this date, *** received both a 6 in one vaccination (containing Distemper / Adenovirus / Parainfluenza / Parvovirus / Leptospirosis and Coronavirus), IN ADDITION to her Rabies vaccination on this date. Current standards of practice at all veterinary schools in the country, including ***, recommend not more than once every three years for core viral vaccinations, including Distemper/Parvo combination vaccinations and Rabies. These are recommendations made by immunological experts in veterinary medicine, due to documented long term immunity to these core viral vaccinations, as well as the risks of severe autoimmune or immunosuppressive disease from vaccinating for these core viruses too frequently. It should also be noted that it had only been 10.5 MONTHS since ***’s previous DAPP vaccination, which had been given on November 3, 2018. I should also note that well respected veterinary medicine vaccine experts, such as W. Jean Dodds, DVM, caution that certain small breeds, such as the Dachshund are even more susceptible to immune reactions from over-vaccination. It also says in all vaccine inserts that the vaccinations are to be given to healthy animals only. *** was suffering from a chronic autoimmune bowel condition, and should never have been vaccinated like this, much less only 10 months apart. It is also recommended that in breeds like Dachshunds multiple vaccinations like this not be given on the same day, as it was in this case. I should also note that including the non-core vaccination Leptospirosis in the combination also should have involved a discussion with as to whether this vaccination was appropriate for *** given her lifestyle, as this vaccination is considered by many to be one of the most immunogenic and reactive of the potential vaccinations given to dogs.
The date of these combination vaccinations is important in this case, as only one month late on October 26, 2019, *** re-presented to, for what called a “knot on her back”, which looked like she may have been bitten by something, yet no altercation with another animal or insect bite was directly observed. In the minimal record provided, the only history recorded said, “checking a spot on the back,” at a location where typically one or both vaccinations may have been given a few weeks earlier. As there were no exam notes from the September 23, 2019, exam, we have no idea where the vaccinations were given. Vaccination lump reactions are common in the days and weeks ahead, especially when polyvalent, multiple vaccinations are given at the same time, and especially in the Dachshund breed. There are no physical exams or SOAP notes provided by on this date either on October 26, 2019. There is a receipt for services provided to me, as well as the listing of “Staff Name” at the top of the receipt, which lists the name of, whom I am not sure is a licensed veterinarian, veterinary technician, or other staff member of. On this date, *** was given a Dexamethasone injection and PCN (antibiotic) injection, while being sent home on Amoxicillin at dose of 100 mg twice daily and a topical solution to apply to the spot on her back.
The next service provided by was on November 6, 2019, where it only says “Recheck” in the minimal records provided to me, as well as a “Staff Name” of ***, whom I do not know either, if she is a licensed veterinarian or veterinary nurse/technician. According to there was little change since October 26, 2019, and therefore surgery was scheduled for November 7, 2019, where according to the minimal record provided, it says “Clean/Flush” with listed under “Staff Name” on that date, however it is not clear whether she is the veterinarian that day or not. On that same day, however an “owner release” is signed, where consents and authorizes, DVM to “prescribe for, treat or operate upon” ***. On the receipt that day is listed “tumor removal”, which I can only assume was the mass or lump from a “likely” vaccine reaction, however no surgical notes were provided, or biopsy performed for definitive diagnosis. This also differs from what the medical notes said earlier and later on, where a “brown recluse spider bite” was noted in the record, which certainly is not the same as a tumor? I am confused on who performed the surgery that day, whether did the procedure or, who was legally given consent to operate on ***. I should also note that did not offer pre-surgical blood work, which should have been routine, minimum standard of care diagnostics offered on a 7-year-old Dachshund with ***’s medical history, as well as to see if there were any underlying metabolic causes that *** may have had, and which could have been a cause of delayed wound healing. On the receipt that day on November 7, 2019, there is no anesthetic listed that was used to “remove the tumor,” which is very problematic, both from a medical record keeping perspective, as well as understanding if any anesthetic was used at all? Once again (as done on June 18, 2019, for an unknown condition) *** was given a Dexamethasone injection, Rimadyl injection, as well as the same Penicillin injection (i.e., PCN) that had not worked the first time on October 26, 2019. Once again *** is sent home on generic Rimadyl (i.e Vetprofen) at a dose of 37.5 mg once daily, even though *** is already on maintenance prednisone for her chronic colitis. It is also highly disturbing that NO further antibiotics were dispensed on the surgical date, even though the lesion was getting progressively worse, with no definitive diagnosis, wound culture (which should have been done) or biopsy performed.
According to ***, he heard loud crying coming from ***’s operating room, after which a veterinary employee emerged saying that he could not take *** home, unless he signed a waiver, which was provided to me for review, in preparation for writing this letter. This “Acknowledgement and Waiver Against Medical Advice” lists that *** had elected to take *** home “under anesthetic without proper medical observation.” However, there is nothing listed in the scant records about which, IF ANY anesthetic was used for the “Tumor removal,” or ANY discussion between and the staff at that *** should stay in the clinic longer for her recovery from surgery. The only other record notation from was the following day on November 8, 2019, where it simply lists “Rebandage,” along with the “Staff Name” of listed, who is also not listed as a veterinary technician or doctor, nor are there any notes about the condition of the wound or bandage changing process. According to, after he got *** home from surgery the bandage was falling off with the post op wound full of blood, at which point he had to place the bandage back on himself. He returned to on November 8, 2019, however, never saw the “supposed” veterinary surgeon ***, DVM to discuss his concerns and fears, as *** was taken into the back, where her bandage was changed, and he was told to return in 3 days after the weekend for a next recheck. *** progressively declined over the weekend from November 8 through November 10 with development of severe lethargy, vomiting, poor appetite, and no thirst, while not producing any urine or stool.
Because *** was rapidly failing, took *** to *** at 4:53 PM on November 10, 2019. Evaluation at the ER showed at the distal end of the suture line, that there was evidence of skin necrosis (i.e., dying, black tissue), as well as rapidly developing cellulitis, with serosanguinous discharge located at the surgical site on the left lateral thorax. Initial assessment and blood work showed upper GI bleeding, melena (digested blood in the stool), acute kidney failure, with creatinine of 9.7 (reference range .5 to 1.3), BUN <140 (reference range 10-26), Potassium 7.1 (reference range 3.4-4.9), as well as severe metabolic acidosis with TCO2 of 13 (reference range 17-25). *** also was clearly septic with white blood cell count of over 65,000 (reference range 5000-16000) and significant left shift with bands present. Urine analysis confirmed acute kidney failure damage with ph of 5.0, plus 300 glucoses in the urine, and a urine specific gravity of 1.010. *** was subsequently admitted for intensive ICU level treatment for gastrointestinal bleeding and acute renal failure. On the following day of admission on November 11, 2019, of the Internal Medicine Service was consulted for an abdominal ultrasound, which confirmed a significant peritonitis with a large amount of peritoneal effusion in the abdominal cavity, along with a “corrugated duodenum” on the ultrasound, which he concluded was due to a high GI perforation. *** states in the medical record that “I have a very high index of suspicion for a high GI perforation, given ***’s clinical presentation and HISTORY OF RECEIVING BOTH STEROIDS AND NSAIDS.” *** spent several days at *** until November 14, 2019, where she was discharged on several medications and almost a $4,000 total bill. Unfortunately, over the next several days, *** did very poorly at home, and was subsequently euthanized on November 19, 2019, due to excessive suffering, poor quality of life and extremely poor prognosis of recovery.
In my 30 years of veterinary medical practice, I have never seen a case so mismanaged on so many levels from the outset of this case that I have documented in chronological order in this letter. The areas of negligence, malpractice, as well as practicing below ANY expected minimal standard of care are evident here, in addition to the atrocious and totally unacceptable medical record keeping in this case. In fact, there is only one date in ***’s 2019 medical history provided on February 25, 2019, where there are acceptable SOAP medical notes for *** on that date. However, NO exam or SOAP notes were provided for the dates needed in this case from October 26, 2019, through November 8, 2019, when *** was under ***’s primary care for the bite or tumor.
Following my initial phone discussion with *** on April 8, 2020, I asked him to contact and obtain the appropriate medical records on the relevant dates from October 26, 2019, through November 8, 2019. *** contacted multiple times on April 9, 2020, to obtain the medical records on these dates, at which point an employee named “***” sent a scant email of minimal records. At 1:42 PM on April 9, 2020, spoke to, (who is supposedly wife) spoke to ***, who told that there are usually exam notes, but for some reason they were not put into the computer, and therefore had no additional medical records to provide. According to he was told that there were no exam notes from October 26, 2019 (date of ***’s first presentation for the supposed bite) or from November 7, 2019 (date of the “Tumor Removal” surgery) or November 8, 2019 (one day post op rechecks). According to ***, he informed me that he was told that usually makes SOAP exam notes, but they don’t have them in this case, and did not know why, nor could they provide more information than they already had.
In my strong opinion for the multiple reasons cited throughout this letter, Mr. ***, who should receive significant damages, including the entire veterinary expenses of almost $6,000 post operatively from the date of the surgery on November 7, 2019. I also feel that there was undue emotional damage incurred both with himself, as well as for ***, who was the ultimate victim of negligence, malpractice, and in my opinion, animal abuse. Please let me know if you have any other questions.
***
PROFESSIONAL CONSULTANCY, ***, D.V.M.
The following details dictate my assessment of a proposed malpractice case concerning Dr. *** who performed a sialocele removal surgery at the *** Clinic on ***, a 4-year-old, male neutered Labrador Retriever canine weighing approximately 72lbs owned by ***.
***’s sialocele removal surgery was performed by *** on September 7, 2022 at the *** Clinic, however due to a recurrent and unresolved swelling at the surgery site described as the right ventrolateral mandibular region, *** was referred to *** where he underwent a second surgery. During this second procedure, it was discovered that a 4 x 4 gauze and a small suture needle were left inside ***’s surgical site and posed as foreign objects which prevented the resolution of the swelling. The medical and surgical management of ***’s visits at both the *** and *** are detailed in the following few paragraphs:
*** initially presented to the *** on July 19, 2022, where a 3cm swelling was noted to be located in the right submandibular region. His case was worked up and on August 26, 2022, a diagnosis of a salivary sialocele was made. *** Clinic recommended removal by a dental specialist. On September 3, 2022, *** again presented to the *** Clinic because the mass had ruptured. The affected area was cleaned and flushed and on September 7, 2022, *** from *** performed the sialocele removal at the ***.
According to Dr. ***’s surgical notes, the surgery was uneventful and the right mandibular and Sublingual salivary glands and associated duct were removed. A penrose drain was placed at the Surgical site to allow drainage of blood/fluid from the area. Each step of the surgical procedure was clearly outlined and the owners were given instructions on post-surgical management and follow-up recommendations.
*** had his first post-surgical recheck on September 12, 2022, where it was documented that his face was still very swollen, and cellulitis was suspected. He was dispensed more antibiotics (Enrofloxacin and Amoxicillin/Clavulanic acid) and pain medication (Carprofen). The penrose drain was removed on September 16, 2022, and the swelling was documented to be better. The notes of the attending veterinarian are as follows:
“Minimal drainage around drain, cleaned openings with chlorhexidine-soaked gauze, transected sutures. Removed drain and performed laser therapy. Swelling decreased by about 50% in size. Ultrasound exam of cheek tissue reveals solid matrix, no pockets of fluid found.”
On September 19, 2022, *** again presented to the *** Clinic because the swelling in his right submandibular region had returned. The attending veterinarian’s notes states as follows:
“R lateral neck is swollen, firm and somewhat well circumscribed over parotid salivary gland. Swelling extends cranially to area around manibular [mandibular] premolars, past midline and midway down the neck. Firm, non-painful and is not hot to the touch. No discharge from incision site or drain removal sites. Assessed swelling with ultraound [ultrasound]. No fluid was detected in any region. Aspirate revealed primarily RBCs, occasional skin cell, non-degenerate neutrophils consistent with peripheral blood and no bacteria. Recommended to leave patient at *** and have Dr. *** assess in AM. Will also contact ***, owner approved.”
The client was advised to hotpack the area as well as continue previously dispensed meds and additional antibiotics (Marbofloxacin) were dispensed.
On October 1, 2022, *** had his first Urgent Care visit at *** and was scheduled for a surgical visit on October 5, 2022. ***’s surgery was performed on Oct 6, 2022, and he was discharged on October 7, 2022. *** recommended that *** have his first post-surgical follow-up approximately 3-5 days post-surgery and sutures removed 10-14 days after the procedure. The following paragraph dictates ***’s case summary at ***:
“*** presented to the *** General Surgery Service on 10/5/2022 for evaluation of a recurrent swelling on his right ventral neck that has been treated previously by his primary veterinarian with surgery and antibiotics. After evaluation of ***’s mass, the decision was made to move forward with a CT scan and surgery. *** underwent general anesthesia for a CT scan and exploratory surgery on 10/6/2022. The CT scan revealed foreign material within his mass. During surgery we removed a small suture needle along with one surgical gauze from within the mass on ***’s neck. His abscess was flushed, a drain was placed, and his incision was closed with stitches. Additionally, a sample of ***’s abscess was submitted for culture. We should have these culture results back within one week. *** did well during surgery and recovered from anesthesia without complication. He is being discharged home to you today for continued supportive care and monitoring as he recovers from surgery. Please see the medication, monitoring, and follow up sections listed below for more information about how to best care for *** at home.”
An analysis of ***’s case reveals an obvious error on the part of *** during his surgical treatment of *** where he accidentally left a 4 x 4 gauze and small suture needle in the tissue. It is not unheard of for surgeons to make this error, however every effort should be made to avoid such mistakes as it can lead to additional unnecessary expenses for the client, unnecessary exposure to anesthesia, patient discomfort and even death. Surgeons should routinely check surgical fields for tools used to perform a task. A recommendation which is usually useful is to count the number of gauze used in the procedure and double check the count prior to closing up wounds to ensure that all have been removed. A surgical assistant can help with this. Suture needles can also be counted as many surgeries require several suture packs be used which can amount to many needles. Foreign materials impair the healing process of wounds and can lead to abscess formation as the body tries to wall off the foreign material. As per the notes and follow-up, the surgical recovery seemed as if it would have gone very well had the foreign objects not been left inside the surgical field since with laser therapy and appropriate medication ***’s swelling and drainage were reduced. This idea is further solidified as ***’s recovery was good after removal of the foreign objects by ***.
In conclusion, it can be said that Dr. *** made an error which led to the patient undergoing an additional unnecessary surgical procedure. While this seems to have purely been a mistake, it can be classified as malpractice and as such, the client should be awarded payment for expenses incurred post the initial surgical attempt by ***.
The opinion supplied in this review is subject to modification if additional information is provided and only for the sole use of the party requesting the opinion. This letter is not for publication without the express permission of the undersigned.
Sincerely,
***, D.V.M.
***, DVM, MPVM
I have been asked to render an opinion regarding the veterinary care of ***, 11 years and 5-month-old neutered male canine Terrier Yorkshire, owned by ***. On 5/6/22 and 5/7/22, *** was seen by ***, VMD, and several other veterinarians of *** Emergency Room (ER) in *** due to weakness, hematuria caused by Urinary Tract Infection (UTI) and vomiting for 2 days prior to the ER visit. I reviewed the following materials to arrive at my opinion: Medical records, clinical summaries, physical examinations, treatment plans, blood work and ultrasound report, invoices provided by ER and Internal Medicine (IM) of *** hospital, photographs of “***” when he was healthy and when he was in the hospital (taken by his owners), client communication emails, written Statement of Facts and chronology prepared by the owner. A reasonable expert in my field would rely on these records and sources of information in rendering opinions of the type sought herein.
Based on my training, experience, medical references, and the preceding information, implementing well-grounded and generally accepted methodologies and theories, I am prepared to give my professional opinion on a more probable than not basis and with a reasonable degree of medical certainty.
Therefore, all views presented in this declaration possess at least this degree of confidence unless otherwise stated.
Based on my review, I, ***, affirm under penalty of perjury that Dr. ***, who provided veterinary services to *** as described in this statement of facts and professional medical opinion, did not adhere to the standard of care required of veterinary physicians in the circumstances of the nature described.
*** had a history of Hyperadrenocorticism / HAC (Cushing’s disease) which was under control with daily Trilostane treatment. He also had history of systemic and pulmonary Hypertension which was managed with Sildenafil treatments. Below are the lists of his medications (prior to the *** visit):
On 5/5/22, *** was not feeling well, he had weakness, inappetence, vomiting, having blood in the urine and wobbly and very sedate during the walk and had splay legged. ***’s owners brought *** immediately to *** internal medicine hospital. *** was seen by ***, DVM, from ***.
On presentation, *** was mildly dehydrated but well-perfused. He was noted to have a grade II/VI systolic heart murmur, distended and very tense abdomen on palpation, and was ambulatory in all limbs but was splay legged where there was no traction. On the blood work, *** had mild Azotemia, hyperkalemia, and hyponatremia and elevated Alkaline Phosphatase (ALP) = 652, elevated Neutrophil (14,000)- indicated infection. An abdominal ultrasound revealed progressive bilateral chronic nephropathy. Dr. *** indicated that from the blood work, it showed that *** had a UTI. She informed ***’s owners that she prescribed *** with antibiotics and painkiller, then she indicated that his urine was clear and no signs of pain afterwards. *** was breathing normally, no more anxiety, and resting comfortably. Since *** was stable, Dr. *** would transfer him to the IM the following morning (5/6/22).
On 5/6/22 and 5/7/22, *** was seen by Dr. ***. She performed the following diagnostic procedures and monitoring on ***:
Dr. *** administered the following treatments (for complete records, please see attached medical records):
On the invoice incurred on 5/6/22, it was listed that Fentanyl citrate 50 mcg/ml 1 ml vial and Methadone HCl 10 mg/ml injection were billed twice (When *** was under Dr. ***’s care), however different veterinarian names (***, DVM and ***, DVM) were listed on the invoice as the veterinarians who administered those drugs twice. These discrepancies continued for all the medications listed (i.e., Methadone charges were billed to ***’s owners on 5/6/22 and 5/7/22, however none of them were prescribed by Dr. *** even though she was the clinician in charge of ***’s care during those 2 days which made validity of these data questionable (Please see emails communication between Mrs. *** and Dr. *** indicating that she was the clinician who oversaw ***’s care on 5/6/22 and 5/7/22).
On 5/6/22, Dr. *** requested authorization from Mrs. *** if she could insert the nasogastric tube to provide nutrients to ***. Mrs. *** declined to authorize Dr.
*** for a nasogastric tube (NG) insertion. She indicated that she would feed him by herself when she visited ***, she also left a voicemail to Dr. *** NOT to put nasogastric tube on ***. Mrs. ***’s objection was due to nasogastric insertion would require the use of anesthesia which could be high risk for patient like *** with history of systemic pulmonary hypertension. When Mrs. *** arrived at the hospital, to her dismay despite her refusal to let Dr. *** to insert NG on ***, he already had NG on him. Mrs. *** noticed that *** was drowsy when she visited him. She asked Dr. *** what made *** so drowsy, her reply that she gave him dexamethasone for his pain. Mrs, *** did not authorize Dr. *** to administer *** with Dexamethasone, this especially knowing that *** illness were due to Cushing and UTI which made Dexamethasone administration contraindicated in these conditions.
On 5/6/22 night, ***’s was in critical state. He remained in oxygen with abnormal respiratory rate and was efforted. He received his trickle feeding through the NG tube. Urinary catheter had been placed. His Urine Output (UOP) were low at 1.4 ml / kg / hr. although not oliguric. He continued to remain uncomfortable despite his CRIs and his blood pressures (BP) were trending down.
On 5/7/22 morning, *** began to rapidly decline, his breathing has gotten more labored and went into cardiac arrest. When he stopped breathing, Cardiac Pulmonary Resuscitation (CPR) was performed, then there was return to circulation, although the mechanical ventilator needed to be continued. Dr. *** was on the phone with Mr. and Mrs. *** and updated them that ***’s prognosis was very grave. She gave the owners either option:
Dr. *** indicated that it was their hospital policy to have a new estimate/deposit before transferring *** to their critical care staff where *** would be working with a new doctor. Humane euthanasia was ultimately elected by Mrs. and Mrs. ***. *** was
given 2 ml of pentobarbital as the euthanasia agent. ***’s death was confirmed via cardiothoracic auscultation. *** passed away on 5/7/22 morning.
In the medical records, Dr. *** did not indicate or confirm what the etiology and the diagnosis that caused ***’s from being stabled and released from the ER to sudden/rapid deterioration after being transferred to the internal medicine on 5/6/22 and led to his euthanasia on 5/7/22. Her actions are considered below acceptable standard of veterinary practices.
For a complete history of ***’s medical records, treatment plans, blood work, ultrasounds, and other diagnostic works, as well as for verification, see medical records of *** (from ER and IM) (See the medical records attached to this letter).
Referenced Facts:
Dr. ***’s failed to obtain consent from Mrs. *** and performed NG insertion despite Mrs. *** objection NOT to expose *** to anesthesia due to his preexisting heart condition. She also failed to obtain consent from the owners prior to administering Dexamethasone, Methadone and Fentanyl to ***. Dr. *** ‘s actions are in clear violation of the AVMA Policy of the VCPR. Moreover, she failed to communicate with Mr. and Mrs. *** what caused ***’s condition to decline so rapidly. In addition to that, she also failed to document in the medical records, what diagnosis the cause of his death was. All misconduct are in violation of AVMA VCPR Policy 1, 2, 3, 4 and 5.
Had Dr. *** done her due diligence and had not administer Dexamethasone to *** which was contraindicated in patient with UTI and Cushing disease and had Dr. *** obtain consent from Ms. *** prior insertion to NG and not to expose ***’s to unnecessary anesthesia risk, *** would likely still be alive. These egregious neglects led to ***’s demise.
Conclusion:
Dr. *** made several significant errors in judgment. She failed to recognize that administration of Dexamethasone was contraindicated in patients with UTI and Cushing disease. Moreover, she also failed to consider that administration of combination of a potent drug combination (Fentanyl and Methadone) in patient with pre-existing heart condition can cause severe cardiac and respiratory depression that leads to patient’s death. All these drug treatments were inconsistent with the symptoms and purpose of the ER visit (UTI). Dr. *** also did not consult or obtain approval from Mr. and Mrs. *** prior to administering the drugs (Dexamethasone, Fentanyl, and Methadone). This egregious act led to ***’s untimely death.
It is my professional opinion that Dr. *** was negligent in her care of ***. This egregious neglect led to ***’s unnecessary severe pain and suffering that led to his demise.
This opinion is based on my 30-plus years of experience as a Veterinary Practitioner.
This opinion is subject to modification in the event additional information is provided and only for the sole use of the party requesting the opinion. This opinion is not for publication without the express permission of the undersigned.
***, DVM
Dr. ***
Email: ***
Re: ***
This letter is my assessment of the sequence of clinical events surrounding the medical management of ***. I have been asked to render an opinion regarding *** veterinary care. *** is a 9-year-old, Quarter Horse gelding who presented to ***, *** on multiple dates from May to September 2022 for lethargy, general malaise and poor performance. Neurologic deficits also developed.
I reviewed the following materials to arrive at my opinion: Medical records including clinical summaries, blood work, text messages and emails prepared by the owner. A reasonable expert in my field would rely on these records and information sources when rendering opinions of the type sought herein.
Based on my veterinary training, 9 years of clinical experience and the preceding information, I am prepared to give my professional opinion on a more probable than not basis and with a reasonable degree of medical certainty. Therefore, all views presented in this declaration possess at least this degree of confidence unless otherwise stated. Based on my review, I, ***, DVM state that there exists a reasonable probability that the care, skill or knowledge exercised in the treatment, practice or work that is the subject of complaint, fell outside acceptable professional standards. It is my opinion that the veterinarian, *** at *** who provided veterinary services to *** as described in this statement of facts and professional medical opinion, did not adhere to the standard of care required of veterinary physicians in the circumstances of the nature described.
*** presented to *** for being lethargic. The owner also reported that *** had a temperature of 38.7 oC which then reduced to approximately 38.oC. Five days later Dr. *** came to evaluate *** and took blood samples for biochemistry, a complete blood count and Lyme disease. Dr. *** recommended scoping for ulcers if blood work all normal. The owner hadn’t reported any clinical signs consistent with gastric ulceration. The owner states they suggested testing for Equine Protozoal Myeloencephalitis (EPM) but Dr. *** said that “he didn’t look like an EPM horse.”
The owner messaged Dr. *** on 3rd June to check if ***’s blood results had been reported (they had just come back the night before). A photo of the blood results was sent to the owner and was told that there was “ever so slight positive” on the Lyme titers. The titers were positive for OspC (1525) and OspF (1306). The laboratory that performed the test, *** state that if both of these titers are positive (>1000 for OspC, >1250 for OspF) then it indicates that an infection occurred several weeks prior and is moving toward the chronic infection stage. Dr. *** stated that she wouldn’t recommend treating titers that low and that she didn’t think that was ***’s “issue”. According to the literature, treatment should be instituted when both OspC and OspF are positive (Cornell University, 2021, Divers et al., 2009). This is particularly true when the area is endemic for Borrelia burgdorferi, the causative bacterium for
Lyme disease: Pennsylvania is considered endemic for the ticks that carry this bacterium and the disease itself (Department of Health). The owner trusted Dr. *** advice and didn’t pursue treatment further at this time.
In the same blood sample, there were other derangements about which Dr. *** didn’t advise the owner. These were hyperkalemia (7.9mEq/L), hypoglycemia (<10mg/dL), hyperphosphatemia (9.1mg/dL), elevated lactate dehydrogenase (LDH, 460 IU/L) and a low sodium / potassium ratio (18). The elevated phosphate was likely due to artifactual hemolysis of the sample in vitro as there was no indication of kidney disease or other causes of hyperphosphatemia on the blood test. The low glucose levels were likely due to inappropriate handling of the sample for this test. The elevated LDH was mild and may have also been related to artifactual hemolysis. While hemolysis can also lead to hyperkalemia, this elevation in potassium is generally mild and in humans it’s been shown to have a linear relationship to changes in platelet counts (Ranjitkar et al., 2017). This has not been proven in horses to date, however, should be considered possible. ***’s hyperkalemia was significant and should have raised concern with Dr. *** as *** was showing clinical signs consistent with hyperkalemia.
On 9th July, the owner took *** to a rodeo and in the warm-up pen doing light work he began pawing and trying to lay down, even with a rider on his back. The owner gave him Banamine (non-steroidal anti-inflammatory pain medication) and electrolytes and he recovered quickly. Dr. *** advised this sounded like a mild colic. This episode is also consistent with exertional rhabdomyolysis (tying-up).
July 19th, the owner requested an appointment as *** had been progressively losing weight. The owner also questioned if his teeth were the problem. On July 29th, Dr. *** examined ***. The owner advised that Dr. *** had come to re-take Lyme disease blood samples and the owner insisted that EPM testing be done. Dr. *** reassured the owner that he “doesn’t look like that” regarding the possibility of EPM. Dr. *** also advised the owner to check if *** had been 5 panel tested for HYPP (Hyperkalemic Periodic Paralysis) on his paperwork. The clinical notes for that day reported that *** had a body condition score of 5/9 and that she “recommended repeat blood work (Vit E for muscle function, EPM, and Lyme) and fecal.” The owner reported that he hadn’t been tested for HYPP. Dr. *** didn’t respond to this message. There are no clinical notes in the file after July 29th, 2022.
On August 8th, Dr. *** reported that *** was negative for parasites and that she wanted to treat for Lyme’s and EPM (per the owner). On August 10th it was reported to the owner that the results for repeat Lyme’s, EPM and vitamin E had been received. The vitamin E result was within the reference range (3.6μg/mL) while the Lyme titers had reduced to “equivocal” levels (OspC: 829, OspF 1209). The EPM results showed that *** was negative for Neospora hughesi while he had positive titers for Sarcocystis neurona (1:2000). This result indicates exposure to one of the causative protozoa for EPM but does not confirm clinical disease. The owner stated in a message that “Lyme’s numbers have gone down since the last one” and Dr. *** responded with “I must be thinking of a different horse”. It’s unusual that Dr. *** didn’t want to treat *** for Lyme disease when his titers were positive and indicative of infection while she then elected to treat *** when his results had reduced. It’s also concerning that she didn’t compare the repeat results with his initial Lyme titers. As *** was showing signs consistent with EPM, treatment would be recommended. Treatment for EPM, Protazil began on August 13th.
On August 14th, 18th, 25th and September 7th the owner requested ***’s lab results which were eventually sent to her on September 8th. Also, on August 14th the owner stated that looking at the blood results ***’s signs made “sense” as he was starting to show possible neurologic deficits “leaving the box crooked and starting to lope sideways”. On 19th August an equine dentist examined *** and stated that there were no concerns regarding his teeth.
On second opinion, the veterinarian (Dr. ***, *** Hospital) felt that the mild colic episode may have been *** “tying up” which is possible however no biochemistry panel was performed after this episode to confirm / refute this. The owner states this was because Dr. *** “believed it didn’t need to be done”. On 9th September, the owner questioned Dr. *** regarding the previous abnormalities. Dr. *** stated in messages that she wasn’t concerned and felt these changes were artifactual. I would disagree with this given the significant elevation in potassium at that time (May 2022). The owner also asked why *** hadn’t been tested for HYPP after she had messaged to state that he hadn’t previously been tested, Dr. *** responded saying “I guess I missed that text message.”
Following this the owner (through Dr. ***) had *** genetically tested for a number of diseases including HYPP; all of these tests came back negative. Repeat testing for EPM was also performed and on SarcoFluor IFAT testing, the titer was 640 which is considered a 95% probability of *** having EPM due to Sarcocystis neurona. On September 20th it was recommended that *** be treated with Marquis and his bloods rechecked in 30 days. On October 11th, ***’s electrolytes including potassium were all within normal limits. Dr. ***’s notes state that *** has Grade 2 neurological deficits in the in both hind limbs (right worse than left).
The owner has stated in an email to me that *** still has neurologic deficits. These may be permanent at this stage possibly leaving *** unsuitable for rodeo work or even ridden exercise though he needs to be evaluated by a veterinarian for this to be confirmed. The only clinical notes for *** by Dr. *** relating to this condition were May 26th and July 29th, 2022. These notes are wholly inadequate. Dr. *** has accepted responsibility twice for the error in ***’s clinical management, once in a text message and once in a letter to the owner.
It is my professional opinion that the clinician, Dr. *** did not provide acceptable care within current professional standards when caring for ***. It is also my opinion that ***’s disease went undiagnosed due to Dr. *** overlooking his significant hyperkalemia and dismissing it as spurious. Due to this, valuable time was lost in starting appropriate treatment.
This opinion is subject to modification in the event of additional information being provided and is for the sole use of the party requesting the opinion. This opinion is not for publication without the express, written permission of the undersigned.
Sincerely,
Dr. ***, DVM
References:
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