20 Ways To Avoid Trouble With Surgery

08-04-2009


Published:

Editor’s Note: Dr. Zeltzman scored a coup in getting the trust representatives of the AVMA PLIT to participate in a conference call for publication. The first part of his report—“10 Ways to Avoid Anesthesia Trouble”—was published in the July issue.

Every day, the trust representatives of AVMA Professional Liability Insurance Trust receive liability insurance claims related to surgery.

The representatives agreed to speak candidly with me to help Veterinary Practice News readers avoid 20 of the most common liability claims over surgical complications.

  1. #5 Not this paw

    During the consultation, the diagnosis should not be the only part of the discussion. It is important to discuss the possible complications so the owner’s expectations are compatible with what you can provide.
  2. Every surgical candidate should have a thorough physical exam. This means not focusing on the tip of the iceberg, such as skin mass, but looking at the rest of the patient. For example, a patient facing ACL repair  may not do as well because he also has hip dysplasia.

  3. Honestly discuss the prognosis. Even a 99 percent success rate means a 1 percent risk of failure.
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  4. Problems, including disastrous mistakes, can occur because of misidentification of a patient. How often do you have two black Labradors in your hospital on the same day? We have all heard of horror stories where the wrong patient was euthanized because nobody took the time to clearly identify the patient.
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  5. Remember the guy whose physician amputated the wrong leg? Well, this happens in veterinary medicine, too: surgery on the wrong knee, the wrong hip, the wrong elbow. This can be especially tricky in veterinary surgery because so many clients may be confused with their right side and their pet’s right side. Therefore, all members of the health care team must ensure that the correct surgical site or side is clearly identified.
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    Similarly, “remove mole” or “remove mass” can lead to frustration and litigation. It is important to be very specific about the exact location of masses. One way to be on the same page as the owner is to circle masses with a permanent marker. It washes off with alcohol.
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  6. “Do whatever you think is best” can mean different things to a client and a well-intentioned practitioner. This is why a detailed, written consent form should be filled in by you and signed by the owner.
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  7. Miscommunication clearly leads to many claims. It is crucial to communicate with the owner, especially if something changes intraoperatively. In this day and age, this may mean having two or three phone numbers, possibly for both spouses. We have all experienced the value of “You can reach me at this number for sure.”
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    Good communication is paramount within the team: the front desk, technicians, kennel workers, doctors. Everybody should be on the same page. Claims sometimes occur because one doctor does the consultation and the admission but another veterinarian performs the surgery.
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    #8 Use proper technique when removing a root

    Open communication with the owner is especially important with dental procedures, as many unforeseen complications may occur. Especially when some factors are unknown, it is important to inform the owner openly of what could happen: “Additional teeth might need to be extracted,” “We might discover problems during the procedure,” “There is so much tartar that I can’t assess the teeth.” Radiographs can be very useful to visualize bone loss, which increases the risk of mandibular fracture.
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  8. A retained root after a tooth extraction can lead to touble, so it is important to use proper technique to ensure that the entire root has been removed.
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  9. Standard of care is constantly changing. “If a practitioner is not able to provide optimal care, including proper care at night, it would be wise to refer the patient,” one PLIT representative says. “This is true not only because we live in a litigious world, but also because we are obligated to do what is in the best interest of the patient.” If the owner refuses to be referred, then document it in the medical record.
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    Our PLIT colleagues believe that “if an owner cannot afford a referral, it would be wise for you not to perform the surgery yourself if you are not confident and competent to do it.”
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  10. Many claims are triggered by bandage and cast complications. At worst, this can lead to amputation. Prevention includes correct bandage placement by properly trained staff as well as education of the owner. Checking the toes for swelling, preventing the bandage from becoming wet, following recommendations for bandage changes are all important steps. A written schedule of the frequency of bandage changes should be given to the owner.
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  11.  

    #11 Two struvite bladder stones were forgotten after surgery in this 6-year-old female pug.
    Postoperative radiographs should be taken when appropriate, for example after fracture repair or after a cystotomy. Some specialists consider it wise to check that all bladder stones have in fact been removed. Likewise, ensuring that a cystotomy or perineal urethrostomy patient can urinate before going home is a wise precaution.
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  12. In cancer surgery, it is imperative to discuss the possibility of not obtaining clean margins after excision of a malignant mass. The possible need for chemotherapy or radiotherapy should at least be mentioned, as well as the consequences of tumor recurrence. Whether the owner can afford follow-up care is irrelevant. What is important is to mention it to the owner and document the conversation.
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    And by the way, histopathology should always be recommended regardless of assumptions about the benign or malignant nature of a tumor, as well as the financial health of the clients. If they decline, assuming that’s even an option at your practice, it should be documented.
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    This means, for example, that thoracic radiographs and blood work should always be recommended in a cancer patient, whatever the cost. From a lawyer’s perspective, failure to document the owner’s refusal would be the same thing as not recommending them at all. Why? Because “If it’s not written, it didn’t happen.”
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    As management gurus have recommended for decades, we should never assume what a pet owner can or will pay, because our job is to recommend what is in the pet’s best interest.
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  13. Thermal burns lead to many claims with the PLIT. They can involve “rice socks,” reusable warming plastic discs, “hard” electric heating pads, LRS bags or latex gloves filled with water. Any warming device that comes out of the microwave might be too hot for a patient’s skin.
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    One suggestion is to invest in an infrared thermometer. For about $50, the device can be aimed at a surface to double check its temperature.
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  14. Although spays are often considered a routine procedure, they lead to frequent claims after deaths caused by an unexplained hemorrhage. Castrations are a close second.  Using appropriate suture material with proper technique and the adequate number of knots should prevent this embarrassing complication.
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  15. Similarly, a dehiscence of the linea alba rarely makes a pet owner happy. Catgut suture is overrepresented in the number of claims. Of course, dehiscence can happen with other suture types. It is typically iatrogenic, rather than due to failure of the suture material: Either the knots were inappropriate or the wrong suture pattern was used or too small bites were taken.
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  16. It is critical to be specific. “Routine spay” is not an appropriate surgery report, especially if the patient dies and the owner sues. The anesthesia protocol, the specific steps of the surgery, normal and abnormal findings, and closure of the surgical site should be detailed. As far as closure is concerned, the nature and size of the suture types, as well as the suture patterns, should be specified.
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  17. Retained or forgotten sponges lead to complaints. There are well-defined techniques to prevent this complication, and they can easily be implemented in practice.
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  18. Urethral tears can occur as a male cat is being “unblocked.” Although our PLIT experts agree that this can happen to even the best, this risk should always be explained to the owner.
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  19. Skin masses should be investigated before a client is told to “just watch it” or “it’s just a fatty tumor.” Such masses should be biopsied, or at least tested with a fine-needle aspirate. Sure, false negatives do exist. If the microscopic diagnosis doesn’t match the clinical evidence, then a second opinion should be requested or the mass retested.
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  20. Pet owners should always be given discharge instructions after surgery, which should be a reminder of what had been discussed during the consultation: dietary recommendations, exercise restrictions, self-trauma prevention, medication schedule and physical therapy requirements.
    Discharge instructions should detail the timing of suture removal, drain removal, bandage removal or changes and fol-low-up X-rays. They should explain what to do in case of an after-hours emergency.

These suggestions may sound like common sense, and they are. They just happen to be what our colleagues at PLIT face every day. The safest way to avoid getting in trouble is to perform a thorough practice audit and an honest introspection with these suggestions in mind.

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Phil Zeltzman, DVM, Dipl. ACVS, is a small-animal board-certified surgeon at Valley Central Veterinary Referral Center in Whitehall, Pa. His website is www.DrPhilZeltzman.com.

This column first apeared in the August 2009 issue of Veterinary Practice News

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