staging.vettimes.com

Blog

The consequences of making a mistake
Beef farms in Scotland can be quite picturesque.

Fertility work makes up a large proportion of cattle veterinary work in the UK and, after spending a month on the farm rotation at university, I can appreciate the importance of getting it right – and how hard it can be.

Experienced large animal vets make it look easy – they scan the uterus and ovaries, and decide what drug to give to aid getting the cow in calf, all in a minute or two.

In the meantime, I’m still fumbling about trying to palpate what, I think, may be the uterus or ovaries while the cow squeezes and gradually cuts off the circulation in my arm until I can barely feel my fingers.

Meanwhile, the vet has zipped through several cows already.

When things go wrong

What happens if you misdiagnose a pregnant cow as negative and administer prostaglandin, or give a cow steroids without realising she’s in calf?

On one fertility visit this week, we discussed when things go wrong. For example, what if:
- you misdiagnose a pregnant cow as negative and administer prostaglandin (PGF_2α)?
- a vet gives a cow steroids for any number of reasons without realising she’s in calf?
The outcomes of both of these scenarios are almost inevitably abortion, which can have a number of repercussions on the farm – and, potentially, the vet.

Negligence or misconduct?

Many new graduates are terrified of being called up for “fitness to practice” for making a mistake such as those aforementioned. However, during a Veterinary Defence Society (VDS) workshop at the SPVS Lancaster weekend earlier this year, it was emphasised a difference exists between negligence and misconduct in the eyes of the RCVS.

What I took away from this session was, in simple terms, negligence involves making a mistake – such as missing a diagnosis, giving the wrong treatment accidentally, eliciting side effects from something due to missing something in the case history – whereas misconduct is actively doing something you know you shouldn’t – such as trying to cover up a mistake, lying or misleading a client.

Mistakenly giving PGF_2α to a pregnant cow would be classed as negligence and, on the whole, the VDS would have your back; the farmer may receive some compensation for his losses, but the incident wouldn’t tarnish your career. In the same situation, misconduct would be denying you had administered any treatment.

In short, you won’t get struck off for easily made, one-off mistakes, but you may if you lie about them.

In the news

Our conversation about accidentally aborting cows led us to discuss the case of Honey Rose, the optometrist convicted of gross negligence manslaughter. News reports vary, but, from what I can gather, she failed to diagnose papilloedema (swollen optic discs) in an eight-year-old boy, which would have been an indication of the hydrocephalus he died of five months later.

It is reported she claimed to have been unable to examine his eyes properly because he had photophobia – a claim considered false by the judge. However, she had also failed to look at retinal photos taken by a colleague, on which the papilloedema was evident.

Going by the RCVS’ rules, missing the diagnosis or not looking at the retinal photos would be negligent. However, denying she’d been able to carry out a thorough examination, despite written records suggesting otherwise, would be misconduct.

Rose was found guilty of gross negligence manslaughter and was handed a two-year prison sentence, suspended for two years, and a 24-month supervision order, and was ordered to complete 200 hours of unpaid work.

In your defence

As vets, we have the VDS to help us in these situations – and, while it would be truly awful to make a mistake resulting in an animal’s death, we would not be at risk of imprisonment.

Doctors and dentists also have defence societies that will fight their corner, but optometrists? To my knowledge, an equivalent does not exist – and this was the first case of an optometrist convicted of manslaughter in the UK, which added to the complexity of the legal battle.

The death of a little boy is devastating, but, as medical professionals know, death is a risk with many procedures, no matter how small the risk may be. It’s frightening to think jail could be a consequence for those in the medical profession.

So, while I gradually lost the sensation in my right arm as I tried to reach an ovary of the 10th cow in a row, I mulled this over and realised I was extremely thankful for the safety net the VDS provides and would not take working with animals for granted.

After all, if I’d decided to be a doctor instead, I could be rummaging around in another human’s back end rather than a cow’s!
- For further details of the Veterinary Defence Society and its services, visit www.thevds.co.uk
October 19, 2016
My various reasons for running
Maintaining a work-life balance can be difficult within the veterinary profession, unless you actively make an effort to do non-vet things.

Although a “poor runner” Jordan is taking on a half marathon in aid of two charities close to her heart.

Joining a sports team or other society requires a certain level of commitment (depending on the level), and this can be helpful to keep a frequent scheduled period of “escape time”.

Another good way to motivate yourself to do “other” things is to set a personal target to aim for.

Procrastination aid

Several months ago, in the middle of fourth year exams, I think I was subconsciously craving any method of occupying time that didn’t involve staring at a textbook – so, in my revision-frenzied madness, I signed up for the Great Scottish Run Half Marathon.

Just filling in the application and perusing training plans gave me a few sweet minutes of procrastination at the time. But after exams had been and gone, and final year rotations loomed, I started to question what an earth I’d gotten myself into.

I’m a poor runner at the best of times, sporting an age-old ankle strain and intermittent shin splits – the furthest I think I’d run before beginning training was 5km (about seven years ago, when I was considerably fitter) – but I gritted my teeth, donned the ankle support and shin splint tape, got a decent pair of trainers and set out on a run.

Staying motivated

Despite my misgivings, by following a training programme almost impeccably, I’ve gradually been building stamina and have surprisingly avoided aggravating my shins.

Now, having nearly finished the training, and with the half-marathon only two weeks away, I can appreciate how much having a target to aim for has helped me keep fit throughout my first few rotations – and with many of them being the sort of rotation notorious for having long hours, it would be so easy to miss out on exercise.

In addition to keeping motivated to exercise, the main aim of my insane challenge (for me anyway) is to raise money for two deserving charities with which I have personal connections.

Determined to finish

Help In Suffering has helped keep the people of Jaipur rabies-free for 14 years.

The first charity is The Air Ambulance Service, which saved my life five years ago when I fell from a horse and sustained near fatal injuries.

The other charity, Help In Suffering, runs a neutering clinic in India where my friend and I gained valuable skills last year, having been let down by another placement and stranded in an unknown country. This charity’s vital work has kept the people of Jaipur rabies-free for 14 years.

I still hate running, but I’m glad I’ve tried to overcome the challenge to support these fabulous charities. While I know it’s going to be tough on the day, I’m determined to cross the finish line and not let down my supporters who have so generously donated.

If you would like more information about the charities, or to donate, please visit my sponsor pages below:
- Air Ambulance – justgiving.com/jnsinclair
- Help In Suffering – justgiving.com/hisrunning
September 19, 2016
The consigned colleague conundrum

Many universities put veterinary students into groups for final year rotations, in which they remain for the year. Others keep students in the same group for the majority of rotations and shuffle them around for selectives only.

However, selective rotations at the University of Glasgow run throughout the year and, to accommodate as many of the students’ choices as possible, we have a different group of students for every rotation.

Another difference between the universities is whether students have a choice with regards to the group of people they are put with.

Familiarity breeds…

Original image © grgroup / fotolia.

Some universities allow students to name one or two people they would like to be in groups with (if possible), or even name students they really don’t want to be in groups with – all in the strictest confidence, of course.

We don’t get a choice at Glasgow, but scope exists to swap groups, once the rotation timetable is released, if you change your mind about selectives or want to avoid someone in particular.

Is one method superior to the others? Being in the same group for the year could result in a strong team who know each other really well and play to each other’s strengths and weaknesses. But, on the other hand, it could also easily become tiresome if niggling annoyances build up throughout the year.

Where students are able to suggest colleagues they would like (or not) to be grouped with, the likelihood of begrudging fellow students in your group could be minimised, but, ultimately, isn’t likely to be eliminated entirely.

Hobson’s choice

Should we get a say, though? In the real world of work (now only nine months away) we aren’t likely to get a choice about who we work with, unless a very strong first impression is made that would make you either very keen to take a job or extremely put off.

Ideally, we need to be able to work with a range of different people – those we do and don’t like – in a professional context and keep personal grievances out of the workplace. Realistically this can be difficult, but we may as well start learning how to do that now.

I think changing groups every rotation provides a balance between being thrown in with people you may not know very well (or like very much) and not being stuck with them for an extended period of time; each of our rotations are four weeks in duration.

So far, I’ve really enjoyed getting to know people I’d previously barely, if ever, spoken to and, in some cases, building solid new friendships. I’m obviously biased because I love Glasgow, but I think we’ve nailed the system perfectly.

August 31, 2016
Communication is key

Recently, I have been engaged in a battle with my internet provider and – ignoring the fact I’ve been without the world wide web for a month – no one seems capable of doing anything about it.

If avoiding angry customers is the aim, communication is key, says Jordan.

Despite these grievances, it’s actually a) the communication factor and b) lack of desire to please the customer annoying me most.

Over the years I’ve worked in retail, and I have been a waitress, during which I was expected to bend over backwards for the customer for fear of garnering a complaint.

I even remember training sessions where we were shown graphs showing the number of complaints received versus words of praise, and how likely the customer would be to spread the word regarding bad service compared to good.

The gist of it all was to not anger anyone because bad news travels fast… and this is just as applicable in the veterinary profession.

The customer is always…

Contrary to the popular saying, the client is most definitely not always right, and as the point of a veterinary consultation is for us to impart our professional knowledge gained through – long and thorough – training, we are obliged to possess pretty fantastic communication skills.

Yes, having to tell a client their beloved pet died unexpectedly during routine surgery is a bit different to being put on hold for the umpteenth time because the advisor on the phone hasn’t read the account record properly, but the underlying principle is the same – so good communication is essential.

As vets, continuity isn’t always possible, but if you have an unknown client on the list you would be expected to brush up on the history and have a vague idea of why they’ve made an appointment. Anything less would be unprofessional – so why do other businesses think this is acceptable?

Strength in numbers

Is there anybody listening?

For these international corporations, the single customer is just a drop in the ocean – losing a few hundred quid a year when I cancel my contract is just pennies to them, and no matter how much of a fuss I kick up, realistically, it won’t touch their reputation.

For vets, however, it’s different – any complaint not only reflects badly on the individual involved, but on the practice and also the profession.

We cannot afford to lose the trust of our clients over silly things like calling a male dog “she” or not spending a few minutes reading through the patient’s notes before they walk into the consult room.

Poor communication is one of the most frequent reasons a complaint is made to the RCVS, and I suspect this is why the vet schools now have a much bigger focus on communication – to help us hit the ground running and (hopefully) avoid such negativity.

Practise makes perfect

Communication skills come with experience, and while they aren’t classically thought of as something that can be taught, we can be armed with certain tools to help us communicate more effectively.

The practical communication skills sessions we’ve had over the years involving actors have been an ideal way of letting us practise dealing with “difficult” clients before being in that situation for real. And now, in our final year, we’ve transitioned into taking our own consults, either with the clinician keeping an eye on us or confirming our findings afterwards and asking the client any questions we may have forgotten.

Being a vet encompasses so much more than clinical knowledge and surgical skills, and my recent phone arguments with various technical support advisors have made me appreciate just how highly trained we are in terms of communication – and that’s something we should aim to maintain to continue to be respected as professionals.

August 17, 2016
Change for the better

The UK veterinary profession is suffering.

While a documented shortage of graduates does not exist as in previous years, significantly less fuss has been kicked up about the announcement of the new Aberystwyth-in-conjunction-with-RVC vet school, compared with the opening of the Surrey Vet School in 2014.

Surrey vet school: a bolt from the blue?

Is this because we knew Aberystwyth was in the pipeline so are not shocked by the announcement, or has the profession kept quiet because we do need more vets?

The problem is not a lack of graduates, but a lack of “experienced vets” and a shortage of vets staying in the profession after a few years of graduation.

This begs the question: why?

The simple answer is, as shown in last year’s “Voices from the future of the veterinary profession” survey conducted by Vet Futures, the profession, in its current state, does not meet expectations of those entering it.

Essentially, we feel undervalued, underpaid and overworked, and lack a sense of life outside veterinary.

Undervalued

The profession has an image problem, in many respects. It is becoming more commercialised, not just because of corporate takeover, but because clients expect more.

We seem to be moving away from the respected professionals who have dedicated their lives to helping animals and, as such, are praised for performing little short of a miracle in medical and surgical feats, and towards the providers of a service that, if not absolutely perfect and costs next to nothing, will only be complained about and bad-mouthed to other customers and competitors.

Sadly, the economic climate has caused much scaremongering, bringing vets to the absolute disposal of the pet owner for fear of losing clients and, therefore, not being able to balance the books.

I feel very strongly part of the reason our services are so undervalued is the NHS (See Jordan’s July 2014 blog post, “I Blame the NHS“).

The everyday person has no concept of how much medical procedures, diagnostics and therapeutics cost. I’ve done the research – prices for private medical care are found fairly easily, but NHS costs? Nigh impossible.

So how can we blame the public for not having a clue how much a radiograph costs? The public perception of veterinary in this country needs to change and I don’t think it will without transparency on human medical costs in conjunction with our veterinary ones.

Overworked

“I struggle to see how many full-time vets’ hours fall within the legal limit,” says Jordan. Image © alarts / Fotolia.

Depending on the kind of practice you’re in, or going into, the relative feeling of being overworked will differ. I realise my points won’t apply to every practice in the country and this is sweeping general opinion on the UK profession as a whole. However, I struggle to see how many full-time vets’ hours fall within the legal limit.

The legislation is complex, with loopholes in the Working Time Regulations 1998 (WTR) possibly allowing certain practices to skirt round some of the “rules”, such as the designated 11-hour consecutive rest break in each 24-hour period and the minimum 24-hour rest break in each 7-day period.

On-call work is difficult to classify, but, in essence, the signing of a workforce agreement (probably as part of an employment contract) means the employee is agreeing to to provide out-of-hours cover that impinges on these designated rest breaks.

Some final year rotations at university I know are well beyond the limits set by the WTR (although the legality is sketchy since we’re not employed while we’re students).

“It’s not a nine-to-five job,” was a comment given with regard to rotation hours. That’s tough love: you’re going to be worked into the ground when you qualify, so you may as well get used to it now. But why? Why can’t veterinary be a nine-to-five job? It certainly is in other countries.

The profession is changing and I really hope this is the kind of change that comes about nationwide. With the increasing popularity of outsourced out-of-hours cover and shift work, why can’t a vet clock off at 5pm, enjoy some exercise, cooking, social activity, whatever and come back to work refreshed the next day ready to put in 110%?

Achieving work-life balance

We have numerous talks at uni about mental health awareness and the importance of work-life balance. But how is it possible to achieve a work-life balance if you’re working from 8am to 8pm and, even on the nights you’re not on call, you essentially only have time to grab something to eat and sleep.

What kind of life is that?

“It’s all very well lecturing us on being conscious of having a work-life balance, but what if it is beyond our control?” Image © DOC RABE Media / Fotolia.

It’s all very well lecturing us on being conscious of having a work-life balance, but what if it is beyond our control, as in so many cases?

I know for a fact, if the profession remains stuck in its ways, I will become just another statistic and leave the UK, if not the profession entirely, within a few years.

Don’t get me wrong, I have loved my rotations so far and the sense of fulfilment when I’m actually getting a handle on things is excellent, but I know I will resent my job if it does not allow for some enjoyment outside of veterinary.

But will it ever change? I think something has to give soon, or the profession will find itself in dire straits before long. How would change come about? If we wait for one practice or chain to provide a great work-life balance and rely on the trend to catch on, I think we’ll be waiting a lifetime. But what if the regulations changed?

I don’t really want to talk about Brexit (I’m sure a little piece of me dies inside every time that word is uttered), but the potential change to employment law (which has mainly been derived from the EU) could allow for changes specific to medical professions to protect us from “burnout”.

Overtime pay should exist in the veterinary world, as it does in any other “normal” job, allowing for those maniacs who want to work 24 hours a day to do so at their leisure (or those who need the extra cash), but not at the detriment to those who don’t wish to. Working out a vet’s base salary as an hourly basis is just depressing. And it shouldn’t be.

I keep hearing phrases such as “the profession is changing” and “it’s an exciting time”. I genuinely hope that is the case and we become the progressive generation we like to think we are, and drag the profession kicking and screaming with us into the modern world of enjoying life outside veterinary and moulding our careers around our lives – not the other way around.

July 30, 2016
Top dressings tips
I attended a meeting held by the RCVS with representatives from the Veterinary Defence Society who warned that dressings can be problematic in terms of complaints and litigation.

Image ©iStock.com/pyotr021

I’ll be totally honest here: I don’t like doing dressings.

I was talking to Laura the other day (one of our team of fantastic RVNs) and, because she’s excellent at dressing wounds (her skills easily surpass mine), I thought I’d ask for her “top tips” on the subject.

Expert advice

Laura’s words of wisdom were:
- The right materials are key – she prefers cotton wool for Robert Jones type dressings.
- Think of the pressure points in advance – how is the limb going to move (or not move) under the dressing with even pressure. Good to pad between the toes, and so on.
- Ideally, leave the toes out so regular checks can be made to make sure no problems are occurring.
Of course, a compliant caregiver at home really helps too.
July 25, 2016
Game on – battle to be top dog in Bailey’s Run!

Introducing our new game – Bailey’s Run!

Lead Bailey the dog on his forest adventure collecting gold coins – but avoid all the nasty bugs along the way. Tap the space bar, or click your mouse, to make Bailey jump – and tap/click it twice for a “super jump”.

The game is compatible with Macs and PCs; however, a mobile app is coming soon. If you experience any difficulties trying to play the game please get in touch – and don’t forget to tell us which operating system and internet browser you are using.

Proud of your score?

Add your points total to our leaderboard in the following format – Julie_Smith. And come back soon for a chance to win some top prizes.

Good luck!

July 13, 2016
Immunotherapy in cats
Although “off-licence”, immunotherapy is well worth considering in our pruritic feline friends.

Feline head pruritus, a result of food allergy. Image by Caroldermoid. Licensed under CC BY-SA 3.0 via Wikimedia Commons.

Of course we need to rule out all other causes of pruritus first:
- Ectoparasites: As well as all the usual suspects, don’t forget Demodex can occasionally cause ventral alopecia and pruritus (that’s the funny flat form, not the cigar shaped one).
- Food allergies: Let’s face it, food allergy is tricky to pursue in cats – and if they have a partly outdoor lifestyle, hypoallergenic diets are of not of any use.
Case study

I recently saw a case that had typical excoriation lesions around the head and neck.

The owner was able to keep the cat indoors on Purina HA Hypoallergenic for six weeks, and was happy to dose monthly with Stronghold. This, together with a good response to steroids, was highly suggestive of atopy.

Serum IgE testing produced a range of high levels to pollens, house dust mite and moulds.

Our friend has recently started on immunotherapy injections and is now starting to show signs of a good response. With the feline response to immunotherapy reported to be higher than that in dogs, this may be something well worth considering in cats.
July 9, 2016
How to anaesthetise a reindeer

I’ve written before about omnicompetency, but the word is mostly used in the sense of vets being able to work in mixed practice and tackle the veterinary care of horses, dogs, cats and farm animals in the same day – certainly, the first thing to come to mind would not be a reindeer.

However, on my recent equine placement, the staff were met with quite the challenge when a reindeer was referred in.

“Reindeer aren’t something you’d expect to see every day in practice,” says Jordan.

With a history of acute coughing/regurgitation, the reindeer in question had a suspected food impaction in the cranial oesophagus. Conscious radiographs and an ultrasound scan (he was a very well-behaved reindeer) confirmed suspicions of foodstuff, but it didn’t seem to be in the oesophagus.

Collaborative anaesthesia

The equine team – with help from one of the farm vets and some phone calls to other colleagues and practices that had dealt with reindeer before – came up with an anaesthetic protocol and proceeded to surgery.

The reindeer was induced with ketamine and xylazine before a gastroscope was used to try to visualise the larynx and trachea.

There appeared to be a diverticulum or outpouching from the oesophagus at the level of the larynx, which is where the food impaction had settled.

This discovery triggered a discussion as to whether our findings could be normal in some reindeer – similar to the Zenker’s diverticulum in people – since its appearance suggested a congenital, rather than acquired, defect.

A gastroscope was used to aid placement of an endotracheal tube and the reindeer was, subsequently, maintained under anaesthesia with isoflurane. He was positioned carefully in consideration of the rumen and ventilated throughout the procedure, which was to incise into the pouch using a lateral approach and remove the impacted food material.

Back to his reindeer games

He recovered well from the anaesthesia and was happily bounding around a paddock before long, eating some specially imported moss provided by his owner.

Reindeer aren’t something you’d expect to see every day in practice, but it was a great example of how veterinary knowledge can be adapted and applied to new situations, with the added benefit of working together with others with varying levels of experience to come up with a solution.

June 30, 2016
Needle aspirate subcutaneous masses

Cytology of a mast cell tumor from a Labrador retriever at a magnification of 1,000x. Image by Joel Mills [GFDL, CC-BY-SA-3.0 or CC-BY-SA-2.5-2.0-1.0], via Wikimedia Commons.
Fine needle aspiration (FNA) is a valuable tool in subcutaneous skin masses.

We have all had those lumps that, on palpation, you are sure are lipomas (being soft, freely mobile and slow growing). Indeed, the vast majority are just such benign problems – however, it is worth aspirating them to be sure.

Felt like lipoma

We recently had a case in a nine-year-old Labrador with a soft subcutaneous mass the owner had been aware of for a month. It felt just like a lipoma.

On checking the lump again two weeks later, this had got noticeably bigger. FNAs of the mass revealed the presence of a mast cell tumour.

Following excision with good 3cm margins, the Lab went on to make a full recovery.

June 20, 2016