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Seeing practice: are we seeing enough?

by
01 February 2016, at 12:00am

Dr David Williams wonders if the veterinary profession has lost some of its gumption – the resourcefulness and initiative that animal owners might expect, by outsourcing emergency work.

A JACK Russell terrier comes to you with a sore eye at 4.30pm on a Friday. What’s the likely diagnosis, the required treatment and does that make your heart sink or your pulse quicken?

Such was the situation on a recent Friday. I was just enucleating the eye of a cat with idiopathic sclerosing orbital pseudotumour (more of that another time perhaps!) in a practice 15 miles north of Cambridge when along came the call from a practice a bit further south of the city than that.

An hour later I was there and sure enough with the powerful illumination from my slit lamp the outline of the lens, luxated forward to fill the anterior chamber, was visible. The intraocular pressure was a crazy 75mmHg and surgery was needed post-haste.

By 7pm the dog was admitted, the lens removed two hours later and by 10 o’clock I could ring the owner and tell her she could sleep soundly as the dog was back awake, tail wagging and ready to be picked up the next morning.

What better a way of spending a Friday evening? I ask you. True, I could have put my feet up and had a glass of wine watching whatever rubbish there normally is on the TV of a Friday night. Maybe the anaesthetist and theatre staff at the vet school would have preferred that, but resolving a painful eye and stopping long-term blindness is tops for an ophthalmologist, believe you me!

The trouble, as far as I see it, is that many vets have outsourced their out- of-hours cover. True, they get a decent night’s sleep but they miss out on the thrill of saving an acute gastric dilation and torsion or delivering a litter of pups by caesarean section. And the animal might get gold standard treatment at an emergency clinic but the owner has to travel miles, meet new vets they have never encountered before and pay...

Well, many uninsured clients just can’t stump up the cash there and then and we have to ask what is the option for a blocked cat at 10 on a Friday evening if £250-plus (or is it £500-plus?) is out of the question? Is there no cheaper way to pass a catheter than doing pre-op bloods and putting an i.v. catheter and a drip up, all at a greater and greater charge?

Maybe I am hopelessly naïve and old-fashioned! And I guess you’ll quite rightly ask what the owner of the dog with the luxated lens should have done if they couldn’t afford the sizeable bill for an out-of-hours lendectomy at the vet school. Pain relief, glaucoma meds over the weekend and an enucleation on Monday I suppose.

But I remember as a student, the times when vets would have a go – a number 11 blade to open the eye, the scalpel handle deftly inserted between globe and orbit to ease out the lens and then the resulting hole sutured with 6/0 vicryl.

Hands up in horror!

Any ophthalmologist reading this will be throwing their hands up in horror, I’ve no doubt, but in the hands of a general practitioner with an interest in ophthalmology and the skill honed from doing many such out-of-hours surgeries, the results were surprisingly good.

Now the advent of many specialist centres, the lack of an RCVS certificate in ophthalmology and the concern re liability if the animal is not referred to an expert have led us into a situation where vets are not prepared to chance it themselves.

Quite right, you may say, and I can see that providing a gold standard of treatment in a referral institution is without doubt the right thing to do where geography and nance are in the animal’s favour. But I’m worried that we have lost the gumption to do it ourselves where insurance isn’t available or where the nearest available referral centre is over 50 miles away.

Gumption? The online dictionary I asked when not quite sure if I was remembering the word correctly says “initiative, resourcefulness, guts, common sense, courage, shrewdness” – it was just the word I was looking for!

Have we rather lost those as a profession? I wonder. Perhaps now we are outsourcing emergencies we don’t see enough of them to know which corners can safely be cut.

The medics are having something of the same problem. I work with the ophthalmologists in our local teaching hospital and the problem they are having is that the European working time directive doesn’t allow junior doctors to work their way through the night.

Quite right, you say – a tired doctor is a dangerous doctor! But this means that ophthalmologists (and of course it’s the ophthalmologists I know about but the same is happening in other specialities) who are now coming to consultant level just haven’t seen the number of emergencies they used to have done when they were there as underlings working through the night.

The acute retinal detachment that needs emergency attention, the cataract patient that returns in the early hours with a painful blind eye suffering from endophthalmitis where sight will be irrevocably lost if the right samples and the appropriate treatment aren’t given immediately: these were the cases that were bread and butter to doctors trained a couple of decades ago, but they mostly turn up in the middle of the night. So if you aren’t there in the wee small hours, you just don’t see them.

But the junior doctors aren’t prepared to do these shifts now without extra payment. And perhaps that’s quite right, just as vets are keen to send their emergencies to an out- of-hours emergency clinic even if it means inconvenience for owners and potentially more euthanasias for animals where the treatment available in such centres is way beyond the pocket of their carers.

We seem to be going around and around in ever-decreasing circles, don’t we? And I can’t see an easy way out.

I remember the days when the clinic I used to work in had three huge rooms. One housed those waiting with their animals, though they had probably been queuing outside for half an hour before the clinic opened.

The second had six tables each with a student performing an examination while the duty clinician patrolled, ensuring all was in order. The third had a large examination table, upon which sat two somewhat more senior vets – residents we would call them now – swinging their legs and waiting for a case to be brought through which needed a blood sample or more detailed examination.

Animals got good quality treatment free in those days. And now I start remembering... between those two rooms was a wonderful oak-lined pharmacy with wooden drawers for agents such as nux vomica and ipekekuana. Now nobody else there knew either of these drugs, but I had had the good fortune (others may argue the opposite!) of having Professor Alistair Steele Bodger as my lecturer in farm animal medicine. If you wanted to know what was the most recent treatment for a condition, Alistair was not your man, but if you were more interested in the history of veterinary medicine he was right up your street!

For ASB ipekek was the perfect expectorant and emetic. Sadly now deceased, he would have been surprised today to find the drug, derived from a flowering plant from Costa Rica, more widely recognised as the name of a Polish grindcore band. The wonders of Google, hey?!

The active ingredient in nux vomica (another pretty hardcore punk band, this time from the States) is strychnine but somehow the good professor never got round to telling us that!