Wednesday, September 7, 2011

Post-op complications and dilemmas

I have a dilemma, and I would like the opinions of those reading - vets, vet students, and pet owners alike.

About 3.5 weeks ago, I saw a small breed dog with a traumatically proptosed eye. The eye was not salvageable, in fact it was mangled. I told the owners that removal was the only option for this eye, and after much arguing, debating, and scrounging to afford it, they came up with the money for an enucleation.

Fast forward to today. The owner calls because the empty, closed eye socket has been having drainage since the surgery 3.5 weeks ago. He has been to his referring veterinarian with the dog, a culture of the drainage has been submitted, and the dog was placed on appropriate antibiotics. Once the antibiotics were stopped, the drainage came back.

Initially, I thought this was likely an infection - probably from the initial trauma to the eye. I did a quick VIN search though, and apparently, a not uncommon complication of enucleation is that some fluid producing tissue (conjunctiva or lacrimal tissue) may get left behind. If this is the case, re-exploration of the socket and removal of this tissue is necessary. In other words, the dog MIGHT need another surgery.

Here are my dilemmas:

1) First, as an ER clinic, we are not supposed to recheck clients. This is done by the general practitioner that normally sees the pet. So, I have not seen the dog and have no knowledge of the character of the discharge, where it's coming from, or any other detailed knowledge of it. I have no idea if this is a surgical complication or a consequence of the dog having been bitten across the eye and deep infection introduced into the socket. The pet HAS been seen by the regular veterinarian, and he is handling follow-up. Thus, I should not offer to recheck the dog. I think. We ER vets have to tread cautiously here.

2) If this is a post-op complication - do I refund the money for the original surgery? Offer to re-explore the eye socket for free (I'm not sure I would know what I'm looking for and thus, would likely have a more experienced surgeon present)? At this point, I have no idea if I have ANY culpability in this outcome. Post-op complications DO happen.

3) Do I call the referring vet and alert him to what I have found in my literature search? The biggest problem here is that the referring vet is none other than the one that was fired from my position years ago. He hates our clinic and takes any opportunity to throw us under the bus. Any other clinic, any other veterinarian, and I would already be on the phone - but I am so hesitant to call this vet. No matter what happens or what the case, he will try to blame me. That's not a good reason not to call, I realize.

I talked this over with our office manager and my husband, and I will tell you what they recommended, but I would like to hear opinions from you guys first.


BSDVM12 said...

Tough one! Is there definitely an infection (sounds like a culture was done, grew bacteria, and was treated with antibiotics appropriate per sensitivity of the culture)? It sounds like it's just unclear whether the infection is a complication of the enucleation surgery itself, or a result of other surrounding trauma to the facial/periocular region.

As a vet student, here are my thoughts:

1. I guess I would only offer a recheck after speaking to the rDVM about offering a recheck and gaining his approval for me seeing the patient back. If approached by the client to see if I would do a recheck, I think I would advise them that that's not usually the way it's done, however, if they want I could talk to the rDVM to see if he would like to share case management at this point.

2. I tend to think that in most situations where a complication occurs (assuming potential complications were discussed with the client before the procedure and the client gave informed consent), financial responsibility should fall on the client. It's tough, though, if the client was not made aware that this was a potential complication, since it sounds like you were unaware of the possibility pre-operatively. On the other hand, though, it's difficult (or impossible) to alert owners to *every* single possible complication that could occur with a given procedure. If you didn't know that it was a potential complication, and had to go searching to find the underlying cause (possible remaining conjunctiva or other tissue), then it's clearly not *that* common of a complication. I would not refund the money from the original surgery. It would seem to be a gesture of good will to offer to re-explore the enuc site at your own cost, but I also don't think it would be wrong to not offer to do so.

3. It doesn't sound like your decision about whether to offer any financial compensation for the first surgery or free/discounted second surgery will have any positive effect on your relationship with this particular rDVM, no matter what you decide. If you do not communicate with him and make no offer for a recheck or surgical explore, I can imagine him saying "Dr Homeless Parrot clearly isn't willing to admit that she made an obvious mistake with your dog's surgery -- that's just the kind of doctor she is. I know that these complications are related to her surgical error, but she just won't admit it." But if you communicate openly and offer to recheck the dog and explore the socket (free, discounted, or regular price), he could also say, "Since she's offering to do all of this extra work for free, Dr Homeless Parrot obviously feels like she did something wrong with the original surgery." Since it could go either way (and neither way would probably improve your relationship with the rDVM), I guess I'd err on the side of doing the best, most open communication you can with the rDVM, even just saying that you've heard this patient is having some problems and you'd like to offer whatever assistance you can provide in helping manage the case if the rDVM would like such assistance and without stepping on his toes.

I'm interested to hear what you decide to do and how it ends up going! Please share when you have an outcome.

Holly said...

As a pet owner, if I had....ER surgery>dealt with referring vet>unhappy with how this is going>called you back>would want you as a second opinion.

I love my vet and I trust him. That said, IF for some reason I was unhappy with the protocol or result of a procedure I would absolutely bring it up with him and let him know I was also going for a second opinion.

Then I'd do it. My first choice for a second opinion would be the surgeon who was initially involved (you) simply because you have/had first hand knowledge of what you did.

So, my suggestion would be to speak to the client to determine if the client has let the other vet know s/he is getting a second opinion and go from there.

Dr. May B. Insane said...

I think my first attempt to comment was lost in cyberspace and I'll likely not word it as well this time but here goes nonetheless.

I'm certainly not an ophthalmologist but I love eyeball stuff and learned a heck of a lot about it when Rusty lost his eye, so here are my opinions for what they are worth.

You are correct in your research that the most common cause of discharge post-enucleation is tear producing tissue left inside. The discharge in that case is typically serous, not purulent. In mild cases, it may not even cause a problem. The fact that the discharge had a positive culture argues to me that it is related to the original infection. You cannot, however, rule out the probability that it is a mixed problem where tear producing tissue created a wonderful culture medium for bacteria left from the infection. Additionally, enucleating a badly infected eye that may even have ruptured during the surgery is an ideal situation to allow tissue to be left behind. Most likely, this is the case and you now have a budding abscess.

How to handle the situation is definitely tricky. Having worked ER as well as private practice, I understand that thin line upon which you must tread.

I think that you will ultimately have to contact the regular vet. You likely won't be happy with yourself if you don't and it will also give him more fuel for his hostility. Hopefully, he is a big enough person to focus on the needs of the patient and client rather than his hostility and y'all can work out an agreement that benefits all.

As for how to handle the finances, I will say that in private practice I would likely perform the surgery at a greatly reduced cost. I always think of the human medicine world where patients pay just as much for second and third surgeries related to post-op complications with no reduction in cost. Post-op complications are a reality that must be faced head on. It helps if they were discussed pre-operatively but, even if not, they still must be faced.

Often, I perform this type of surgery for the cost of anesthesia without charging for my time or something to that effect. I have, on occasion, done things like that free but I warn you to choose your client carefully since I've been burned by this. I don't understand the phenomenon but it seems to actually make some people more angry to do it for free than just to give a discount.

Would your clinic be open to allowing you to do the surgery at a greatly reduced cost? If so, I would suggest that you discuss the issue with the regular vet and propose that solution with him still doing the follow-up from there. Maybe even invite him to be part of the surgical team??? You know him, I don't. The great part about doing a re-explore is that not only can you remove any remaining tissue but you also get to flush out that potential abscess at the same time.

Hope those thoughts are helpful. Best of luck with a bad situation.

Anonymous said...

I think it needs to see an ophthalmologist, honestly. It's what I'd do if it were my pet, even if I performed the original surgery.

Anonymous said...

While I understand the problem with the other vet, you need to tell him anyway. Unless the case gets handled by another vet, he's the one handling it, and needs to know. What he does, and how he behaves, is on him.
You might want to tell the client yourself first - that way, if he throws you under the bus, the client already knows. And no one is perfect.
I don't think you're actually culpable, but it certainly would be a nice gesture to offer to do another surgery free - if you can find someone with the experience to be sure it will be effective.
I suppose referral to a specialist would be ideal, but sounds like the client can't afford that.
Has anyone cultured the fluid btw?
I'm coming from the perspective of a client btw, with some medical knowledge.

Karen Whiddon said...

I'm just a pet owner, but if I were in this position, I would expect the ER Vet to ask me why my regular vet is not handling this. Then, as unpleasant as it may be, a phone call to this other vet is in order. Or a fax - faxes are very nice to avoid actual personal contact!

In a perfect world though, the vet that did the surgery should do the follow up - for free. If more surgery is needed to clean up the first one, as a pet owner I'd expect it to be done by the first operating vet.

That's just me. I'm interested to see what other people say.

Anonymous said...

Not a vet here...

Since the owner called you, I would think it would be completely reasonable for you to tell them you'll consult with the referring vet and get back to them, but that you don't want to step on any professional toes. I would contact the referring vet (in writing -- email or fax or whatever, not on the phone where emotion can get the best of you), tell him you were contacted directly by this owner, and since you did the original surgery would be happy to re-examine the dog at no cost and do whatever follow-up is indicated. I'd make it clear you just want to help, and if the referring vet doesn't want you to "interfere" (or however he would see it) then I'd say fine and walk away, and tell the owner that it's a conflict of interest and they should discuss the situation with referring vet.

If for some reason he agrees (seems unlikely), I'd take it from there. If you feel another surgery is warranted, I agree that a steep discount would be in order (but not free). I certainly wouldn't, as an owner, expect a refund of the previous surgery -- all surgeries come with risks and that's just life.

Angie in MN

Elizabeth said...

As a pet owner I certainly never expect that complications from a surgical procedure are treated free. I generally understand the risks of any procedure. I certainly greatly appreciate a discount in that situation though. I had one of my labs have a soft tissue cancer removed from his hock and his incision split open as there was not enough skin to properly close the incision. I knew this could happen because of the need to get clean margins.. It took 8 weeks and frequent dressing changes while it healed. While it was not free I was only billed every third visit. I was very grateful and made sure my Vet knew it..

I do like the suggestions from Dr. May Be Insane!

VetVoyeur said...

As a pet owner I wouldn't expect a refund for the original surgery because I'm aware that unexpected complications are always a possibility. However,I would hope that the rDVM and ER vet could set aside differences for the benefit of my pet and after a reasonable and understandable explanation of the likely problem, I would be grateful if the vet who performed the original surgery offered to go back in at a reduced cost. VV