Thursday, October 7, 2010

Hard to share

There is something I have wanted to share on my blog for a long time, but I am afraid of the response it will generate. I pride myself on honesty and morality as a veterinarian. I do not believe in lying to owners to cover mistakes, and it irks me to no end to know that there are dishonest doctors out there. Recently, however, I entered a gray zone, and for the life of me, I didn't know what to do.

Several months ago, I took a dog to surgery for an abdominal exploratory. It was somewhat involved but successful. When closing a dog surgically, there are 3 layers. The first is the body wall. It is the single most important layer of all. If those sutures come out, the intestines and other organs will fall out - often under the skin, since the other sutures will stay in. One of the first things you learn in surgery is how to make sure your body wall closure is perfect. The next layer is the subcutaneous fat and tissue. This is mostly to bring the incision together so that the skin sutures (or staples) look neat, and the incision is lined up. I will reiterate - the layer that matters is the body wall.

In school, you have to close the body wall with simple interrupted sutures. This means you make a knot, then cut your suture, then make another knot, and so on. In an abdominal exploratory surgery where the incision can be a foot or more long, this can be enormously tedious and time consuming, as well as unnecessary. Once you are a confident surgeon, simple continuous (rather like a whipstitch) is perfectly acceptable.

Back to the story: I finished my body wall suture and cut the ends of my suture. I looked at them and thought, "those might be too short...they might come out." Then I mentally lambasted myself for being such a damned worrywart, checked everything, and continued. I do tend to be overly, overly careful in surgery and often fret about things that - in retrospect - were not worth fretting over. Something bothered me about this closure, though.

Longer story shorter: 3 days later, the dog came back in for dripping from his incision. His skin sutures were still in, as were his SQ. However, as I ran my hand down the external body wall, I could feel my fingers go into a cavity. The sutures had come out. I delivered the bad news to his owner. I had to go back in and fix the sutures. The owner had already spent well over $2000 on the surgery, and finances were rapidly becoming tight. They were emotionally distraught.

I asked her had she been letting the dog, Flip, jump, run, or play excessively? She turned positively green and admitted that Flip had been jumping in and out of her huge SUV for the past several days. Additionally, he had been rough-housing with the other dog in the house.

And therein lies the question: had I known that the dog was appropriately cage rested as recommended for any major abdominal surgery, I could say for sure that it was my sutures that failed. Yet, she had been letting him jump in and out of her Escalade - putting enormous strain on his abdominal incision. Further, he was wrestling with another dog 2 days post-exploratory. This is a huge no-no. Still, there was that nagging concern I'd felt when I closed the dog up that the sutures wouldn't hold for some reason. Was this me just fretting, as I always, always do, or did I have a legitimate concern? As I said, had I known that the owner had followed the post-op care instructions to the letter, I would have gladly replaced the sutures for free. Yet, I knew she had not - and I couldn't decide who was to blame - me or her, or even a combination of both.

In the end, I did not tell the owner of my concerns. Why? Because I cannot separate my natural sense of worry about any surgery I do from the reality of it. The knot was secure, but the tags were shorter than I usually cut. Had the dog been rested, though, I don't think there would ever have been a problem. I don't think. But I don't know.

Striving for an ethical compromise, I charged about 1/2 of what I would have had I know for sure that it was the owner's fault.

It still bothers me because it's such a gray area and I truly don't know the answer. The dog did wonderfully and is fully recovered. Had I overdosed him on a medication, had I cut him accidentally when taking his catheter out, had I let him fall off a table and break his leg...I would have taken full responsibility because I would have known that those things were my fault.

In this case, I have questions but no answers. Don't judge me too harshly.


Anonymous said...

Tails too short? Physicians often leave their tails shorter than we do, from what I've seen.

What I think is you looked at the incision and noticed something *subconsciously* that told you the sutures wouldn't hold (tissue integrity? number of sutures vs. length of incision? suture material? shape of incision? concerns about owner compliance?).

You'll never be able to figure this one out, but remember to listen to that little voice telling you "something isn't right" because it will save you more often than not.

I've been there.

Anonymous said...

If you had a "feeling" something wasn't right you should have done something about it. The client should not have been charged anything. You are the expert and the buck stops with you.

The Homeless Parrot said...

Anon 1: What I thought when I looked at it was exactly what I said - that perhaps my tails were too short and my knot would pull through.

Anon 2: You obviously missed the point. There is no way to know for sure what happened. The owner was letting the dog be way, way too active after major abdominal surgery. I always question EVERYTHING I do in surgery - if I have to anastamose bowel end-to-end, I often spend a while staring at my anastamosis and asking myself "is this going to hold?" That's the nature of surgery. So I cannot and will not ever know whether this was my natural sense of caution or whether my knot truly wasn't as secure as I thought. I have never shirked my responsibility as the expert and had I known for sure that *I* and I alone made a mistake that led to this, I would have done it for free in a heartbeat.

However, doing something free admits that I did something wrong, and I cannot know if that was the case here.

Life in vet school said...

FWIW, I think your decision was reasonable. Your suturing technique in this case could easily have contributed to the failure. The owner's management once the dog went home could also easily have contributed. By charging half the normal price, you acknowledged that both factors were potentially contributing, and distributed the responsibility evenly between the two of you.

If the woman was genuinely out of money and was going to euthanize the dog over it, I would probably have done it for free (since it COULD have been entirely my fault). But in this case, what you did sounds totally appropriate.

Holly said...

You know, you cannot control owner compliance so the question I would ask is "was the owner given instructions to keep the dog quiet for X number of days?"

if the owner was given that information then it was not about your surgery.

however, that said....I think you must learn a hard and valuable lesson here.....if you are questioning yourself about what a suture line looks like, look at it from the viewpoint the client may not be compliant with post-op care and will this hold? If the answer is no, do what you have to do to keep the patient as safe as you can.

the more I think about this, the more I question the client though. Who lets their dog who had major abdominal surgery wrestle with another dog 2 days post-op? That qualifies as stupid I think.

Holly said...

oops, I should have made it clear the client was stupid, not you.

The Homeless Parrot said...

LiVS: Yes, that is how I saw it, as well.

Holly: I did not discharge the dog. It went to the day practitioner for continued care the following morning, and they did discharges. I would assume that they addressed the no exercise issue. I know that when the owner left our clinic, the dog was lifted into her car by our technician and told no to allow jumping in/out of the vehicle.

I really think that some owners do not realize how serious an exploratory surgery is - perhaps because it's a dog and not a human??

Anonymous said...

>>What I thought when I looked at it was exactly what I said - that perhaps my tails were too short and my knot would pull through.>>

Okay. Shrug.

After many years in practice, I still don't always know why I occasionally suddenly KNOW things I have no reason for knowing. But I've learned to use those sudden, unexpected thoughts as an excuse to take a moment to step back and brainstorm, even though I certainly don't tell clients I'm listening to a little voice in my head (that doesn't go over well).

Mary said...

From everything I've read here (as I do not know you personally) you are an extremely thorough vet. I'm sure that if there were something really wrong with the way you'd done the first level of stitches, you would have done something to correct it before you did the other layers and let the dog go.

Personally, I put the blame on the owner. She didn't follow the instructions. With that amount of jumping and roughhousing she allowed, I wouldn't be surprised if they would have come out even if you'd cut them a bit longer.

Seeing as she turned green when you asked the question, she knew what she'd allowed was wrong -- she probably just thought that it wouldn't happen to her dog, or never completely understood the severity of what could happen if she didn't follow the post-op instructions.

I think you were more than fair in sharing in the cost, and hopefully the owner learned her lesson about post-op activity and listening to your vet!

Holly said...

I've been thinking more on this.

Every single vet/vet service I've ever dealt with has told me no vigorous excercise till the recheck and suture removal. Even those vets that *know* me and know I won't do it, state it.

So I'm sure she was told.

Nope, I'm still putting at least the biggest part of responsibility on the owner.

Elizabeth said...

I think considering everything that what you did was completely fair.

The Homeless Parrot said...

Anon 1: I didn't mean to be defensive. I was just trying to be precise in what I thought. Those were truly my exact thoughts at the time. I agree that listening to your gut is a vital part of being a doctor, but you must admit that it's an inexact science at best.

Anonymous said...

>>I agree that listening to your gut is a vital part of being a doctor, but you must admit that it's an inexact science at best.>>

Well, I suppose it is inexact, in the sense that "something isn't right" covers an infinite number of possibilities. My point was sometimes the unconscious mind detects a potentially problematic pattern before we consciously analyze the situation. IOW, it's not "gut", it is truly brain.

KateA said...

FWIW, while our vet school forced the simple interrupted on us in surgery class, many surgeons argue that SI actually has a higher rate of failure as well as irritation from excessive knots for reaction. You are also more likely to make have more room between sutures with the SI, leaving room for strangulating bowel hernias.

In those super long incisions, I will split the difference and do a couple of simple continuous sections. Not sure if it does anything differently, but it does make me feel better.

And I would totally disagree that it if you had a bad feeling about the length of your tips that it means anything other than it was different than what you normally do and that Murphy's Law is a beast. Vets are often superstitious about things and one little thing off makes us thing bad things would have happened.

Pamela said...

I think you did it right. The owner obviously didn't protect the dog enough, you might have done a bit better on the stitches, but the truth is you'll never know the answer. So, you handled the situation well.

Sorry this was a hard one.

Nicki said...

I think I would have handled it exactly as you did. Obviously there was a compliance issue but I always feel bad when something goes wrong with my surgery, even if it wasn't my fault. FWIW I always do an interuppted pattern, it makes me sleep better, even if it's just a cat spay.

Suzena said...

I recently came accross your blog and have been reading along. I thought I would leave my first comment. I dont know what to say except that I have enjoyed reading. Nice blog.

The Homeless Parrot said...

Thank you all for the supportive and positive comments. I sincerely appreciate them all, and they have eased my mind a bit.