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Examples of actual redacted case reviews

Oct 21, 2022

The following is my assessment of the clinical events surrounding a malpractice case involving *** an 8-year and 5-month-old, 4.76 Lbs/2.16 Kgs female spayed Yorkshire Terrier dog belonging to ***. The medical care and procedures evaluated in the present document took place on October 3, 2022, at *** Hospital, located at ***. The attending veterinary doctor, in this case, was DMV ***.

The diagnoses confirmed or suspected, together with the procedures and administered treatments as prescribed by the attending veterinarian, and actions that have contributed to or might have caused ***’s death are explained in detail and marked with bullet points below:

On September 29, 2022, *** was presented in the previously mentioned clinic for a general consult. Following this consult, *** received a defleaing product and an injection (Cytopoint, Zoetis) to treat her atopic dermatitis. Cytopoint is a synthetic monoclonal antibody that targets a patient’s immune system. *** was discharged on the same day and scheduled for October 3, 2022, for dental work procedures (dental bacterial plaque and calculus removal and possible dental extractions) and pre-anesthetic bloodwork.

On October 3, 2022, aside from a series of abnormalities noted on the oral cavity and musculoskeletal system examination, all other aspects of ***’s clinical and physical evaluation were registered within normal limits.

The blood work examination revealed a series of alterations, such as increases in liver enzymes (ALT – 334 U/L, reference range 10 – 125 U/L), an enzyme found throughout the body, but mainly in the liver (GGT – 20 U/L, reference range 0 – 11) and a type of proteins (globulins 4.9 g/dL, reference range 2.5 – 4.5 g/dL). Although ALT is a liver-specific enzyme, there is a multitude of conditions that can lead to its increase. These causes include cellular damage, inflammation, infection, neoplasia, toxic causes, drug-induced or endocrine disorders. Other causes of ALT include cardiac or skeletal muscle damage and pancreatic conditions.

Further, GGT can increase due to bile duct issues, or it can be drug-induced. Globulins increase in states of dehydration, chronic immune stimulation, neoplasia, or inflammation. The diagnosis established by the attending veterinary doctor was stable/persistent/chronic hepatopathy.

  • Chronic hepatopathies in dogs usually evolve with a series of clinical signs, such as anorexia, lethargy, vomiting, weight loss, jaundice, excess water consumption and frequent urination, and fluid accumulation in the abdomen (ascites). *** did not have any of these clinical signs.
  • On the clinical and physical examination performed on September 29, 2022, there are no notes regarding any suspicions of metabolic, gastrointestinal, or hepatic illnesses. On October 3, 2022, the tentative diagnosis assessment based on the blood work results mentioned that *** had stable/persistent/chronic hepatopathy. *** was never registered in the previously mentioned clinic with any clinical signs specific to liver disease, nor was she documented through blood work results with any form of hepatopathy. However, the diagnosis established by the attending veterinarian implies that the condition was known, and more importantly, it was stable.
  • A definitive diagnosis of chronic hepatopathy is based on liver tissue biopsy. A liver biopsy can be performed surgically or through ultrasound-guided needle aspiration. Biopsied tissue can demonstrate the type and severity of liver disease and guide a veterinary doctor toward a prognosis and appropriate treatment options. The attending veterinary doctor did not perform any of these procedures, and the diagnosis of stable / persistent / chronic hepatopathy was based on simple guessing.
  • While the American Animal Hospital Association (AAHA) states that “increases in the liver enzymes of an otherwise healthy patient are not an absolute reason to avoid anesthesia,” it is necessary also to understand that ***’s actual condition was never fully and thoroughly evaluated. It is also AAHA that clearly states that a “preanesthetic patient evaluation identifies individual risk factors and underlying physiologic challenges that contribute information for development of the anesthetic plan. Factors to be evaluated include the following: History: Identify risk factors, including responses to previous anesthetic events, known medical conditions, and previous adverse drug responses.” In ***’s case, liver enzyme increases were never documented before, and the actual cause of these alterations was still unknown. It would have been impossible to properly evaluate anesthetics risk factors if the definite diagnosis was unknown. Also, there was no way of knowing how to adapt the anesthesia protocol appropriately to ***’s condition.

 

At 9:43 am on October 3, 2022, the attending veterinary doctor called ***’s owner, informing them that *** had a cardiac arrest and was not responding to cardiopulmonary resuscitation (CPR) maneuvers.

  • ***’s morning drop-off was at 8:00 am, the scheduled procedure started at 9:15, and at 9:42, she went into cardiac arrest. It is unclear why, but it is evident that a rush of procedures and patient anesthesia resulted in ***’s cardiac arrest. It is also unclear why the attending veterinary doctor considered that *** was not responding to CPR just one minute later after starting resuscitation procedures.
  • There are some inconsistencies in the medical files regarding patient anesthesia monitoring. Data input suggests that the clinic staff member monitoring the patient registered vital signs, inhalant anesthesia, fluid administration, and oxygen flow rate every 5 minutes. *** was put under anesthesia at 9:15, went into cardiac arrest at 9:42 am, and CPR procedures ceased at 9:55 am. However, for reasons not mentioned in the files, data input stops at 9:35, with only five sets of registered information (9:15, 9:20, 9:25, 9:30, and 9:35 am). As communicated by the owner, the attending veterinary doctor justified that they have no explanation of why *** passed, aside from the fact “that she turned her back for an unspecified amount of time, and notice ***’s heart had stopped.” It is unclear why *** was left unsupervised since there should always be a veterinary technician monitoring the anesthesia protocol and patient vital signs. It is also unclear if the sets of information are missing because it was never registered or removed from the monitoring chart.
  • The attending veterinary doctor made a high-risk decision to proceed to anesthetize a case clearly suffering from an unknown condition, resulting in the loss of the patient. A safe and ethical conduit would have been to postpone the dental procedure and schedule *** for further investigations to establish an accurate diagnosis. As mentioned by AAHA, “Risk factors and individual patients’ needs provide a framework for developing individualized patient plans and may indicate the need for additional diagnostic testing or stabilization before anesthesia. Individual practice procedures may include a minimum database of laboratory analysis, electrocardiogram, and diagnostic imaging for different patient groups.”

 

Pet owners have the right to be clearly informed about any risk involved in general anesthesia, all the more in cases where the patient is suffering from any form of kidney, heart, or liver disease or any other type of illness that may result in death or other definitive or debilitating conditions. In this case, AAHA mentions that “Client communication is important at all times, but especially before anesthetic procedures.” and veterinary doctors should “Obtain written informed consent after discussing the patient assessment and risks, the proposed anesthetic plan, and any available medical or surgical alternatives with the client.”

  • The attending veterinary doctor failed to communicate blood work results and risks implied by general anesthesia with ***’s owners and never performed a risk assessment in this case. Also, ***’s owners never signed an informed consent agreeing to the fact that even if *** was suffering from what was still an unknown liver condition, they still wanted the dental procedure performed, with all the risks implied.

 

There are other inconsistencies regarding the registered data on the physical examination. On October 3, 2022, the medical file notes state that *** had normal skin and hair coat, and the otoscopic (ear) examination was normal. However, physical examination notes from September 29 say that *** had skin erythema on her thorax and lumbar area (consistent with atopic dermatitis), was infested with fleas, and had a brown exudate in her ears (consistent with otitis externa). These conditions cannot be cured over the span of four days.

Another essential aspect that needs mentioning is that Cytopoint is a relatively new drug, approved for marketing in the United States of America in 2015. It is safe to consider that the time lapsed from its approval is insufficient to know all its side effects and interactions with other types of drugs, including anesthetics. As communicated by ***’s owner, On September 29, the attending veterinary doctor rushed the dental work appointment for October 3, even if the attending veterinary technician mentioned that they were already fully booked. A safer conduit would have been to allow some passing of time from administering a drug that interacts with the patient’s immune system and a deworming treatment metabolized by the liver.

To conclude, based on 12 years of clinical veterinary experience, my professional opinion is that ***’s death was a result of a series of decisions taken by the attending veterinary doctor involving a high degree of risk. Due to negligence or lack of knowledge, the attending veterinary doctor thought very little of ***’s condition and proceeded to put her under general anesthesia even if she was suffering from a clear but undiagnosed liver condition.

I, ***, DVM, state that there exists a reasonable probability that the care, skill, or knowledge exercised in the treatment, practice, or work that is the subject of the complaint fell outside acceptable professional standards and that such conduct was cause in bringing about the harm. I also find there to be negligence in failing to disclose known risks fully, complications, and alternatives to the surgery, treatment, and medications.

Considering the acts of malpractice described in the present letter, I believe *** should receive significant damages for financial and emotional losses, including the entire veterinary expenses from October 3, 2022. ***

Sincerely,
DMV, Ph.D. ***

Nov 26, 2022

The following is my assessment of the clinical events surrounding a malpractice case involving ***, a 5-year-old, 170lb entire male American Bully dog belonging to ***. The medical care and procedures evaluated in the present document took place within ***, located at ***. The attending veterinary doctors, in this case, were DVM *** and DVM ***.

On October 6, 2022, *** displayed multiple episodes of vomiting that started during the night (4:00 to 5:00 am). According to the owner’s statement, aside from vomiting, *** did not display any other clinical signs and could walk outdoors alone. The owners suspected that *** was dehydrated and decided to take him to the emergency room, specifically ***.

From 5:00 to 6:00 am, on the same day, the attending veterinary doctors at *** started *** on a non-specific treatment, including intravenous (IV) fluids, to correct dehydration, and pain management. *** underwent a series of investigations, including an abdominal ultrasound examination and chest radiographs. The diagnosis following these investigations was foreign body intestinal obstruction following the ingestion of a toy. The owners were informed that *** required emergency surgical intervention to relieve the intestinal obstruction (remove the ingested toy). The clinic staff reassured ***’s owners that this surgery was routine. *** was a large breed dog, and the clinic could not accommodate him and referred him to another veterinary hospital, specifically ***.

According to the owner’s statement, *** was bright, alert and responsive during the transfer to ***, meaning that his general clinical state and appearance were not altered. The owner documented ***’s evolution and can provide proof of his condition.

The diagnoses confirmed or suspected, together with the procedures and administered treatments as prescribed by the attending veterinarian, and actions that have contributed to or might have caused ***’s death, are explained in detail and marked with bullet points below:

*** arrived at *** between 4:30 to 5:30 pm on October 6, 2022.

***, DVM, the attending veterinary doctor, reevaluated the clinical state of *** and approved his preparations for the surgery. On the initial physical examination, *** had pink (normal) mucous membranes and normal cardiac and bilateral lung sounds on auscultation.

***’s body condition score registered in the initial medical chart was 9 out of 9. Also, the attending veterinary doctor noted that *** was an intact male (not neutered). However, his general description in the patient information section states that he was neutered. *** was, in fact, entire.

  • According to the World Small Animal Veterinary Association, in a dog with a body condition score of 9 out of 9, ribs cannot be felt under a very heavy fat covering, and there are large fat deposits over the neck, chest, spine, and base of the tail, waist and abdominal tuck are both absent. There is also obvious abdominal distention, and a broad, flat back may also be present. According to the owner’s statement, *** was a muscular dog, had a good body condition score, and was in good physical condition. His owners can demonstrate his physical appearance with the most recent pictures.

 

The attending veterinary doctor reassured ***’s owners that relieving intestinal obstructions is a common type of surgery, explained possible complications and risks associated with any surgery, and recommended gastropexy. Briefly, gastropexy is a surgical procedure sometimes performed in large-breed dogs to prevent gastric dilatation and volvulus (GDV), also known as bloat. This procedure consists of a suture of the stomach to the right side of the body wall and holding it into place, preventing it from making the twist that results in GDV.

On admission, *** was bradycardic (had a low heart rate), displayed respiratory effort, had a normal systolic blood pressure of 122 mmHg (normal systolic blood pressure in dogs – 110 and 160 mmHg), and had a normal blood glucose of 83 mg/dL (normal range – 60 mg/dL to 111 mg/dL). The attending veterinary doctor did not perform further blood work investigations before or after the surgery and based their diagnosis and intervention protocol on the results and medical information received from the previous clinic.

At 7:00 pm, *** received the pre-operatory (before surgery) medication which consisted of Ondansetron 0.3mg/kg IV every 8 hr, Unasyn 30mg/kg IV every 8 hr (a broad spectrum antimicrobial drug) and Fentanyl continuous rate infusion (CRI) 5mcg/kg/hr IV. Other medication administered to *** included Maropitant 1mg/kg IV every 24, Metoclopramide CRI 2 mg/kg/day, and Gabapentin, an antiseizure and pain relief drug (the administered dose is not specified in the medical file).

Fentanyl is a very potent opioid analgesic (50 to 100 times more potent than morphine) used to provide profound intraoperative analgesia in dogs and cats and can also be used at low dose rates for postoperative analgesia. Fentanyl has a rapid onset of action after IV administration and a short duration of action (10–20 min depending on dose). After prolonged administration (>4 hours) or high doses, its duration of action is significantly prolonged as the tissues become saturated. Postoperatively Fentanyl can be given by a continuous rate infusion to provide analgesia, doses at the low end of the dose range should be used, and respiratory function monitored. Intraoperative administration is likely to cause respiratory depression. Therefore, respiration should be monitored, and facilities must be available to provide positive-pressure ventilation. Rapid IV injection can cause severe bradycardia, even asystole. Thus, the drug should be given slowly. A reduction in heart rate is likely whenever Fentanyl is given, and treatment should be administered to counter bradycardia if necessary.

Fentanyl dosage for intraoperative analgesia is 5 μg (micrograms)/kg i.v. q20min or 2.5–10 μg/kg/h when administered on a continuous rate infusion during anesthesia. During the postoperative period, Fentanyl should be reduced to 1–5 μg/kg. While there are very few contraindications for Fentanyl administration, product insert and specialty literature mention that it is contraindicated in patients with known intolerance to the drug or other opioid agonists.

Medical notes mention that while the owner was visiting ***, his respiratory rate and effort increased, and he became hypotensive as his blood pressure decreased to 86 mmHg. *** also had an episode of profuse hematochezia, an intestinal bleed usually coming from a colonic site or the upper gastrointestinal tract when associated with accelerated intestinal motility. To counteract the hypotension, *** received 10ml/kg bolus fluids (a rapid infusion of IV fluids) and was further induced under general anesthesia for the surgery. His blood pressure remained decreased, reaching 80 mmHg, and he required another bolus of fluids. Prior to the surgery, ***’s blood pressure was 102 mmHg.

  • There are no explanations offered in the medical notes for this acute episode.

 

Once stabilized again, *** was taken to surgery. ***, DVM, performed the surgical procedure.

  • According to the owner’s statement, the previously mentioned episode of hypotension and hematochezia occurred immediately after Fentanyl administration. ***’s clinical state altered drastically within two to three minutes after the Fentanyl administration. The observed clinical signs, as described by the owner, included raised body temperature, blank stare, unresponsiveness, had a bowel movement, struggled to breathe and was gasping for air (“he looked as if he was taking his last few breaths of life”). Since *** was left unsupervised immediately after Fentanyl administration, the owner immediately alerted the clinic staff and the veterinary doctor present in the proximity and asked if the reaction displayed by *** was typical for the administered treatment. The medical doctor assured the owner that the clinical signs observed in *** were normal. However, on a quick patient evaluation and cardiac auscultation, the veterinary doctor immediately escorted the owner out of the room. According to the owner’s statement, *** became unresponsive immediately after the Fentanyl administration. The owner did not receive any explanations for this episode, nor were they informed that *** had clinical signs compatible with gastrointestinal bleeding. There are no notes regarding monitoring respiratory function in ***’s medical file, aside from a series of sporadic registrations of the respiratory rate.
  • ***’s severe episode occurred after Fentanyl administration was not registered in the medical files to warn other attending veterinary doctors that he might display severe life-threatening reactions to this potent opioid.
  • It is essential to understand that while ***’s owners do not have a medical background, they were able to accurately describe all clinical signs associated with a severe reaction post-Fentanyl administration.
  • Fentanyl depresses both respiratory rate and tidal volume (tidal volume is the amount of air that moves in or out of the lungs with each respiratory cycle). *** displayed increased respiratory effort and was gasping for air.
  • Fentanyl is also documented to activate vagus nerve activity. The Vagus nerve controls specific body functions, including digestion and heart rate. Vagus nerve stimulation may lead to vomiting, increased intestinal motility, and diarrhea. *** had a bowel movement immediately after the Fentanyl administration.
  • Due to its way of activity, Fentanyl toxicity signs include blank stare, difficulty standing and general weakness, unresponsiveness or even unconsciousness, severe difficulty breathing, vomiting and diarrhea. With the exception of vomiting, *** displayed all symptoms of intolerance to Fentanyl.
  • It is unacceptable that a patient was given the maximum dose of a highly potent opioid and immediately left unattended.
  • The attending veterinary doctor did not inform the owners that *** had hematochezia (gastrointestinal bleeding), nor were they explained the meaning, clinical significance, possible causes, and prognosis of this condition. Even if ***’s owners had signed an informed consent regarding the potential risks associated with general anesthesia and surgical intervention, they were not entirely aware of his actual state. No investigations were proposed or developed for hematochezia.
  • The attending veterinary doctor did not inform the owners that *** was hypotensive before him being taken into surgery, nor were they informed that hypotension is a potentially life-threatening condition.
  • Ondansetron has potent antiemetic effects. This drug was developed for and is particularly useful in controlling emesis (vomiting) induced by chemotherapeutic drugs. As stated by specialty literature and product insert, one of the main contraindications of Ondansetron is intestinal obstruction, a condition *** clearly had. Also, Ondansetron product warnings clearly state that this drug can mask progressive ileus and gastric distention following abdominal surgery, and patients should be carefully monitored for decreased bowel activity, particularly in patients with risk factors for gastrointestinal obstruction.
  • Maropitant (inhibitor of vomiting reflex) is generally not recommended in gastrointestinal obstruction or perforation.
  • Metoclopramide is an antiemetic and upper GI prokinetic (causes the contents of the stomach to empty faster). The main contraindication for this drug is gastrointestinal obstruction or perforation.

 

The pre-operatory ultrasound examination revealed that *** had a large amount of fluid in his stomach. This excess liquid was aspirated through an orogastric tube, placed before the surgery to prevent regurgitation and aspiration of stomach content. After being induced under general anesthesia, another nasogastric tube was inserted into ***’s stomach for the aspiration of excess gastric fluid.

  • Although fluid and gastric content were still suctioned out of the patient’s stomach, the attending veterinary doctor administered medication orally (through the nasogastric tube and into the stomach).

 

Following the surgery, which ended at 12:00 am, *** was evaluated by ***, DVM. Medical notes state that he had a normal respiratory rate, and there are no notes in the medical files that might indicate that he was critical or unstable. The clinic contacted the owners and informed them that the surgery went well and *** “did very good.”

Postoperative treatment consisted of Gabapentin (the dosage is not mentioned in the medical file) administered through a nasogastric tube, Fentanyl 3 μg/kg/hr and Metoclopramide 2 mg/kg/day.

On the second day, October 7, 2022, *** was evaluated and treated by ***, DVM. The physical examination notes mention that *** was dull to depressed, resting in lateral recumbency, but was lifting his head and trying to sit up during the examination. Medical file notes clearly acknowledge the fact that ***’s state might have been secondary to anesthesia and pain medication and that the Fentanyl dose was decreased to 3 μg/kg/hr.

  • While the attending veterinary doctor wrote in the medical file that the Fentanyl was decreased to 3 μg/kg/hr, the dosage of Fentanyl administered to *** immediately after the surgery was also 3 μg/kg/h. As such, there was no actual decrease in the administered Fentanyl.

 

Medical notes mention that *** still required aspiration of gastric fluids through the nasogastric tube. According to the medical notes, *** was alert and responsive,
“turning his head around/trying to bite and growling.” Up until this point, there were no indications that *** was in a critical condition or that there was a risk of him passing.

At 10:30 am, the owners came to the clinic to visit ***. According to the owner’s statement, the clinic staff had a calm demeanor, and there was no indication of *** being in critical condition. The owners were asked to wait until *** received his treatment.

The administered treatment included Maropitant 1mg/kg IV every 24, Ondansetron 0.3mg/kg IV every 8, Unasyn 30mg/kg IV every 8, Fentanyl CRI 3mcg/kg/hr IV, Metoclopramide CRI 2 mg/kg/day, and Gabapentin (dosage is not mentioned in the medical file).

Briefly after being asked to wait until *** received his treatment, the attending veterinary doctor informed the owners that he had gone into cardiorespiratory arrest and asked the owners if they wanted cardiopulmonary resuscitation performed for 10 minutes. Unfortunately, a return of spontaneous circulation (ROSC) was not obtained.

According to the owner’s statement, the attending veterinary doctor was in a state of panic and repeatedly apologized to the owners for ***’s passing.

  • THERE IS NO EXPLANATION DOCUMENTED IN THE MEDICAL FILES FOR ***’S PASSING. THERE IS NO MENTION OF VOMITING, COUGHING OF ANY INTENSITY, ASPHYXIATION, OR OTHER CLINICAL MANIFESTATIONS.
  • The explanation offered to the owners was that *** vomited and asphyxiated with gastric content aspirated into the lungs. It is essential to mention that *** had both a nasogastric and an orogastric tube placed into his stomach to aspirate excess fluid.
  • THE ATTENDING VETERINARY DOCTOR NEVER PROPOSED A NECROPSY/AUTOPSY TO CONFIRM THE ACTUAL CAUSE OF THE UNEXPECTED DEATH AND SENT *** TO BE CREMATED.

 

There are other essential inconsistencies in ***’s medical files. He was registered as a Mastiff Mix. In fact, *** was an American Pit Bull. An accurate breed registration is essential as some dog breeds have specific drug allergies or intolerances and are prone to particular congenital illnesses that may interfere with anesthesia protocol and the overall outcome of medical treatments.

To conclude, based on 12 years of clinical veterinary experience, my professional opinion is that ***’s death was, without a doubt, a result of a series of poor case documentation, poor case monitoring and management, and disregard for side effects *** clearly displayed to Fentanyl administration. There is very little consideration for ***’s actual state, and the administered treatment had a more general approach rather than patient-specific.

I, ***, DVM, state that there exists a reasonable probability that the care, skill, or knowledge exercised in the treatment, practice, or work that is the subject of the complaint fell outside acceptable professional standards and that such conduct was cause in bringing about the harm. I also find there to be negligence in failing to disclose known risks fully, complications, and alternatives to the surgery, treatment, and medications.

Considering the acts of malpractice described in the present letter, I believe *** should receive significant damages for financial and emotional losses, including the entire veterinary expenses from October 6 and October 7, 2022. ***

Sincerely,
DVM, Ph.D. ***

JUL 30, 2022

***, DVM, MPVM

I have been asked to render an opinion regarding the veterinary care of ***, 11 years and 5-month-old neutered male canine Terrier Yorkshire, owned by ***. On 5/6/22 and 5/7/22, *** was seen by ***, VMD, and several other veterinarians of *** Emergency Room (ER) in *** due to weakness, hematuria caused by Urinary Tract Infection (UTI) and vomiting for 2 days prior to the ER visit. I reviewed the following materials to arrive at my opinion: Medical records, clinical summaries, physical examinations, treatment plans, blood work and ultrasound report, invoices provided by ER and Internal Medicine (IM) of *** hospital, photographs of “***” when he was healthy and when he was in the hospital (taken by his owners), client communication emails, written Statement of Facts and chronology prepared by the owner. A reasonable expert in my field would rely on these records and sources of information in rendering opinions of the type sought herein.

Based on my training, experience, medical references, and the preceding information, implementing well-grounded and generally accepted methodologies and theories, I am prepared to give my professional opinion on a more probable than not basis and with a reasonable degree of medical certainty.

Therefore, all views presented in this declaration possess at least this degree of confidence unless otherwise stated.

Based on my review, I, ***, affirm under penalty of perjury that Dr. ***, who provided veterinary services to *** as described in this statement of facts and professional medical opinion, did not adhere to the standard of care required of veterinary physicians in the circumstances of the nature described.

*** had a history of Hyperadrenocorticism / HAC (Cushing’s disease) which was under control with daily Trilostane treatment. He also had history of systemic and pulmonary Hypertension which was managed with Sildenafil treatments. Below are the lists of his medications (prior to the *** visit):

  • Vetoryl once per day (SID) in the morning (4/2/22-5/2/22)
  • Viagra (Sildenafil) 0.75 ml twice per day (BID) = 15 mg BID.
  • Simentra 0.75 ml SID = 7.5 ml.
  • Pentoxifylline 50 mg three times per day (TID).
  • Vitamin E
  • Probiotic
  • Gastroelm supplement.

On 5/5/22, *** was not feeling well, he had weakness, inappetence, vomiting, having blood in the urine and wobbly and very sedate during the walk and had splay legged. ***’s owners brought *** immediately to *** internal medicine hospital. *** was seen by ***, DVM, from ***.

On presentation, *** was mildly dehydrated but well-perfused. He was noted to have a grade II/VI systolic heart murmur, distended and very tense abdomen on palpation, and was ambulatory in all limbs but was splay legged where there was no traction. On the blood work, *** had mild Azotemia, hyperkalemia, and hyponatremia and elevated Alkaline Phosphatase (ALP) = 652, elevated Neutrophil (14,000)- indicated infection. An abdominal ultrasound revealed progressive bilateral chronic nephropathy. Dr. *** indicated that from the blood work, it showed that *** had a UTI. She informed ***’s owners that she prescribed *** with antibiotics and painkiller, then she indicated that his urine was clear and no signs of pain afterwards. *** was breathing normally, no more anxiety, and resting comfortably. Since *** was stable, Dr. *** would transfer him to the IM the following morning (5/6/22).

On 5/6/22 and 5/7/22, *** was seen by Dr. ***. She performed the following diagnostic procedures and monitoring on ***:

  • Abdominal Fluid Scoring System/AFAST
  • Thoracic Focus Assessment with sonography for trauma, triage, and tracking (TFAST).
  • Pack Cells Volume / PCV / Total Solid / TS / Lytes.
  • Hydration status, pulse oximetry

Dr. *** administered the following treatments (for complete records, please see attached medical records):

  • Dexamethasone sodium phosphate 4 mg/ml injection/0.13 mg/kg, 0.68mg / Intravenous / IV q (every) 24 hour/hr.
  • Baytril 2.27% injection/22.7 mg / ml / 9.33 mg/kg 47.7 mg IV q 24 hr.
  • Viagra 20 mg Tablets Sildenafil/2.94 mg/kg. 15 mg/per-os (PO) q 12 hr.
  • IV fluid-Plasmalyte/17 ml/hr/q 4 hr-85 ml/kg/day
  • Oxygen administration.
  • Continuous Rate Infusion/CRI — Tube Feeding 1.2 ml/hr. q 4 hr. / vital high protein (HP) liquid diet via nasogastric (NG) tube- 30 kcal/day trickle feed.

On the invoice incurred on 5/6/22, it was listed that Fentanyl citrate 50 mcg/ml 1 ml vial and Methadone HCl 10 mg/ml injection were billed twice (When *** was under Dr. ***’s care), however different veterinarian names (***, DVM and ***, DVM) were listed on the invoice as the veterinarians who administered those drugs twice. These discrepancies continued for all the medications listed (i.e., Methadone charges were billed to ***’s owners on 5/6/22 and 5/7/22, however none of them were prescribed by Dr. *** even though she was the clinician in charge of ***’s care during those 2 days which made validity of these data questionable (Please see emails communication between Mrs. *** and Dr. *** indicating that she was the clinician who oversaw ***’s care on 5/6/22 and 5/7/22).

On 5/6/22, Dr. *** requested authorization from Mrs. *** if she could insert the nasogastric tube to provide nutrients to ***. Mrs. *** declined to authorize Dr.
*** for a nasogastric tube (NG) insertion. She indicated that she would feed him by herself when she visited ***, she also left a voicemail to Dr. *** NOT to put nasogastric tube on ***. Mrs. ***’s objection was due to nasogastric insertion would require the use of anesthesia which could be high risk for patient like *** with history of systemic pulmonary hypertension. When Mrs. *** arrived at the hospital, to her dismay despite her refusal to let Dr. *** to insert NG on ***, he already had NG on him. Mrs. *** noticed that *** was drowsy when she visited him. She asked Dr. *** what made *** so drowsy, her reply that she gave him dexamethasone for his pain. Mrs, *** did not authorize Dr. *** to administer *** with Dexamethasone, this especially knowing that *** illness were due to Cushing and UTI which made Dexamethasone administration contraindicated in these conditions.

On 5/6/22 night, ***’s was in critical state. He remained in oxygen with abnormal respiratory rate and was efforted. He received his trickle feeding through the NG tube. Urinary catheter had been placed. His Urine Output (UOP) were low at 1.4 ml / kg / hr. although not oliguric. He continued to remain uncomfortable despite his CRIs and his blood pressures (BP) were trending down.

On 5/7/22 morning, *** began to rapidly decline, his breathing has gotten more labored and went into cardiac arrest. When he stopped breathing, Cardiac Pulmonary Resuscitation (CPR) was performed, then there was return to circulation, although the mechanical ventilator needed to be continued. Dr. *** was on the phone with Mr. and Mrs. *** and updated them that ***’s prognosis was very grave. She gave the owners either option:

  1. To let *** pass or
  2. Started mechanical ventilator.

Dr. *** indicated that it was their hospital policy to have a new estimate/deposit before transferring *** to their critical care staff where *** would be working with a new doctor. Humane euthanasia was ultimately elected by Mrs. and Mrs. ***. *** was
given 2 ml of pentobarbital as the euthanasia agent. ***’s death was confirmed via cardiothoracic auscultation. *** passed away on 5/7/22 morning.

In the medical records, Dr. *** did not indicate or confirm what the etiology and the diagnosis that caused ***’s from being stabled and released from the ER to sudden/rapid deterioration after being transferred to the internal medicine on 5/6/22 and led to his euthanasia on 5/7/22. Her actions are considered below acceptable standard of veterinary practices.

For a complete history of ***’s medical records, treatment plans, blood work, ultrasounds, and other diagnostic works, as well as for verification, see medical records of *** (from ER and IM) (See the medical records attached to this letter).

Referenced Facts:

  • In another article of “Differential Effects of Fentanyl and Morphine on Intracellular Ca2+Transients and Contraction in Rat Ventricular Myocytes”, the author stated that 7/30/2022 Fentanyl and morphine directly depress cardiac excitation-contraction coupling at the cellular level. Fentanyl depresses myocardial contractility by decreasing the availability of intracellular Ca2+ and myofilament Ca2+ sensitivity. In contrast, morphine depresses myocardial contractility primarily by decreasing myofilament Ca2+ sensitivity. This article is consistent with ***’s clinical condition after Dr. *** administered Fentanyl and Methadone (like morphine in its effect but longer lasting) which caused cardiac depression. *** had a pre-existing condition of pulmonary hypertension due to heart failure. Fentanyl and Methadone are contraindicated in patients with heart failure. Dr. *** made significant errors in judgment by administering CRI of Fentanyl and Methadone and caused cardiac depression which ultimately caused ***’s untimely demise.
  • Polzin DJ et al., the authors of observational case study in the article “Frequency of urinary tract infection among dogs with pruritic disorders receiving long-term glucocorticoid treatment,” indicated that in 127 dogs receiving glucocorticoids for > 6 months and 94 dogs not receiving glucocorticoids. Bacterial culture of urine samples was performed in dogs receiving long-term glucocorticoid treatment, and information was collected on drug administered, dosage, frequency of administration, duration of glucocorticoid treatment, and clinical signs of UTI. For dogs not receiving glucocorticoids, a single urine sample was submitted for bacterial culture. Multiple (2 to 6) urine samples were submitted for 70 of the 127 (55%) dogs receiving glucocorticoids; thus, 240 urine samples were analyzed. For 23 of the 127 (18.1%) dogs, results of bacterial cultures were positive at least once, but none of the dogs had clinical signs of UTI. Pyuria and bacteriuria (present vs absent) were found to correctly predict results of bacterial culture for 89.9% and 95.8% of the samples, respectively. None of the urine samples from dogs not receiving glucocorticoids yielded bacterial growth. This case study is consistent with ***’s condition while having a UTI and receiving an immunosuppressant will further weaken his immune system. Dexamethasone is a potent corticosteroid with predominantly glucocorticoid effects which causes patients with UTI to decline further clinically due to immunosuppression and would have not been able to fight the infection. In addition to contraindication on patient with UTI, administration of Dexamethasone is contraindicated as well for patient with Cushing disease. Dr. *** made significant error in judgment that led to ***’s death.
  • According to American Veterinary Medical Association (AVMA), the Veterinarian Client-Patient-Relationship (VCPR) is the basis for interaction among veterinarians, their clients, and their patients and is critical to the health of animals. A VCPR is present when all the following requirements are met:
    1. The veterinarian has assumed the responsibility for making clinical judgments regarding the health of the patient and the client has agreed to follow the veterinarians’ instructions.
    2. The veterinarian has sufficient knowledge of the patient to initiate at least a general or preliminary diagnosis of the medical condition of the patient. This means that the veterinarian is personally acquainted with the keeping and care of the patient by virtue of a timely examination of the patient by the veterinarian, or medically appropriate and timely visits by the veterinarian to the operation where the patient is managed.
    3. The veterinarian is readily available for follow-up evaluation or has arranged for the following: veterinary emergency coverage, and continuing care and treatment.
    4. The veterinarian provides oversight of treatment, compliance, and outcome.
    5. Patient records are maintained.

Dr. ***’s failed to obtain consent from Mrs. *** and performed NG insertion despite Mrs. *** objection NOT to expose *** to anesthesia due to his preexisting heart condition. She also failed to obtain consent from the owners prior to administering Dexamethasone, Methadone and Fentanyl to ***. Dr. *** ‘s actions are in clear violation of the AVMA Policy of the VCPR. Moreover, she failed to communicate with Mr. and Mrs. *** what caused ***’s condition to decline so rapidly. In addition to that, she also failed to document in the medical records, what diagnosis the cause of his death was. All misconduct are in violation of AVMA VCPR Policy 1, 2, 3, 4 and 5.

Had Dr. *** done her due diligence and had not administer Dexamethasone to *** which was contraindicated in patient with UTI and Cushing disease and had Dr. *** obtain consent from Ms. *** prior insertion to NG and not to expose ***’s to unnecessary anesthesia risk, *** would likely still be alive. These egregious neglects led to ***’s demise.

Conclusion:
Dr. *** made several significant errors in judgment. She failed to recognize that administration of Dexamethasone was contraindicated in patients with UTI and Cushing disease. Moreover, she also failed to consider that administration of combination of a potent drug combination (Fentanyl and Methadone) in patient with pre-existing heart condition can cause severe cardiac and respiratory depression that leads to patient’s death. All these drug treatments were inconsistent with the symptoms and purpose of the ER visit (UTI). Dr. *** also did not consult or obtain approval from Mr. and Mrs. *** prior to administering the drugs (Dexamethasone, Fentanyl, and Methadone). This egregious act led to ***’s untimely death.

It is my professional opinion that Dr. *** was negligent in her care of ***. This egregious neglect led to ***’s unnecessary severe pain and suffering that led to his demise.

This opinion is based on my 30-plus years of experience as a Veterinary Practitioner.
This opinion is subject to modification in the event additional information is provided and only for the sole use of the party requesting the opinion. This opinion is not for publication without the express permission of the undersigned.

***, DVM

Nov 07, 2022

The following is my assessment of the clinical events surrounding a malpractice case involving ***, a 10-year and 11-month-old, 57lb female spayed Basset Hound and Beagle mixed breed dog belonging to ***. The medical care and procedures evaluated in the present document took place within *** Hospital…

*** was a registered patient of ***, a different veterinary clinic, since August 2021, where she was seen for her clinical evaluation and monitoring of a series of blood parameter alterations and an undiagnosed condition. Blood work analysis performed within this clinic revealed that *** had persistently increased alkaline phosphatase (ALP), calcium level and triglycerides. Urine analysis also indicated persistent protein loss, specifically microalbumin (microalbuminuria). The attending veterinarian did not consider these blood work alterations a priority and suggested dental work for a fractured tooth. ***’s owners requested a second opinion for the persistent blood work alterations and the necessity of a dental procedure at the *** Hospital, the clinic evaluated in the current document.

  • As stated by specialty literature, ALP comprises a heterogeneous group of enzymes widely distributed in mammalian cells. Alkaline phosphatase activity is a valuable serum biochemical indicator of liver disease, particularly cholestatic conditions, but may also reflect pathologic changes beyond those of hepatic origin. Bone disease, endocrine diseases (Cushing’s / Hyperadrenocorticism, Hyperparathyroidism, Hypothyroidism, Diabetes), hepatic neoplasia and carcinomas, nodular hyperplasia, idiopathic vacuolar hepatopathy, and other disorders can result in increased alkaline phosphatase activity. In addition, ALP activity may increase due to induction by certain drugs such as glucocorticoids and anticonvulsants;
  • Increased blood calcium levels can result from neoplasia, endocrine diseases (Hyperparathyroidism, Hypoadrenocorticism), bone diseases including multiple myeloma and leukemia, and lytic bone lesions;
  • Increased triglycerides may be associated with endocrine diseases (diabetes mellitus, hypothyroidism and hyperadrenocorticism), liver, intestinal and pancreatic diseases, renal disease (the exact mechanism of influence is not yet fully understood), neoplasia (canine lymphoma) and drug therapy. Specialty literature states that while the estimation of triglycerides is less commonly included in routine profiles, measurements should be performed when lipemia (turbidity of the sample) is detected, as it may reveal important information about the patient’s health status and, just as important, it can interfere with the production of accurate laboratory results;
  • Microalbuminuria may indicate a compromised kidney function and is a significant finding of primary renal disease or renal injury secondary to other systemic diseases, such as inflammatory disease, chronic infections, metabolic disease (hypertension, Cushing’s Syndrome, diabetes mellitus, hyperthyroidism) and neoplasia.

 

The diagnoses confirmed or suspected, together with the procedures and administered treatments as prescribed by the attending veterinarian, and actions that have contributed to or might have caused ***’s death, are explained in detail and marked with bullet points below.

On October 5, 2022, *** was presented at the *** Hospital for a general consult and a second opinion regarding the need for a dental procedure and the safety of general anesthesia, considering ***’s history of persistent altered blood and urine work. Following this consultation, the attending veterinary doctor performed a clinical and physical evaluation and a set of blood work investigations such as blood biochemistry and complete blood count (CBC). Urine analysis was not performed.

The obtained results indicated an increased ALP of 400 U/L (reference range 5 – 160 U/L) and decreased reticulocyte hemoglobin 23.6 pg (reference range 24.5 – 31.8). The blood work panel also included symmetric dimethylarginine (SDMA), an amino acid used for early diagnosis of impaired kidney function. However, results could not be generated as the analyzed sample had increased hemolysis and lipemic index.

According to the notes made in the medical file, the attending veterinary doctor suspected that the results were consequent to benign vacuolar hepatopathy or benign nodules, and recommendations were to pursue further investigations only after the general anesthesia and dental procedure. Also, the attending doctor advised the owners to “look up Liver Enzymes in Dogs” on the internet and mentioned a specific website where they could document themselves.

  • While the increase in ALP was not considered severe, a simple comparison with the previous blood work could have warned the attending veterinary doctor of the presence of an aggravating undiagnosed underlying disease. The prior set of analyses performed four months earlier, on June 8, 2022, revealed a level of ALP of 266 IU/L (laboratory reference range 5 – 131 IU/L). The compared results show an essential increase in ALP. In the medical files, the attending veterinary doctor noted that *** had “steadily elevating ALP since 8/9/21” but did not consider this observation to be of interest and felt comfortable proceeding with the dental procedure.
  • The American Animal Hospital Association (AAHA) describes reticulocyte hemoglobin (RETIC-HGB) as a reflection of the quality of new red blood cells, generally related to the amount of iron available during the formation of these cells. The most common causes of low RETIC-HGB are blood loss and inflammatory disease, leading to decreased iron availability for RBC production. A low RETIC-HGB result may indicate a severe underlying illness before an increase in reticulocytes (the number of new red blood cells) or anemia and should be a warning for further exploration. This finding was not considered, and no further investigations were proposed to the owner.
  • An increased hemolysis index or a hemolyzed sample can be defined as the presence of hemoglobin, the red pigment within red blood cells that carries oxygen. The sample is considered hemolyzed hemoglobin escapes outside the red blood cells (before, during, or after a blood sample is collected) and modifies the properties of the analyzed sample and the accuracy of obtained results. Hemolysis most often occurs after blood collection, outside the patient’s vascular bed, as a consequence of improper blood sampling, which may include the blood sample being collected too fast, too slow, with too much suction on the syringe plunger, or through a too narrow needle. However, hemolysis can also occur inside the patient’s blood vessels (intravascular hemolysis) and may be caused by toxins, infections, abnormalities present at birth, drugs, or antibodies that attack the red blood cells. Without further investigations, it is difficult to know where the hemolysis occurred, and additional analysis should be performed in patients suspected of an underlying disease. The attending veterinary doctor did not propose further investigations regarding the high hemolysis index.
  • Sample increased lipemia index refers to an opalescent aspect of the analyzed sample due to increased triglycerides and cholesterol. As mentioned at the beginning of the letter, in ***’s case history, the observation of increased triglycerides should have determined the attending veterinary doctor to perform further investigations, as this parameter is often associated with severe, chronic and even incurable illnesses. More importantly, on her previous blood work, *** had severely increased triglyceride levels of 883 mg/dL (reference range 29 – 291 mg/dL). The attending veterinary doctor did not propose further investigations regarding the high lipemia index nor determine blood triglyceride levels.
  • While previous urine analyses (urinalysis) performed within the first clinic revealed significant alterations that might have been consistent with the early onset of kidney disease, the attending veterinary doctor did not consider it necessary to repeat this investigation. Urinalysis is an essential check for urinary tract diseases, kidney dysfunction before renal failure happens, metabolic conditions such as ketosis and diabetes, liver abnormalities, and intravascular hemolysis. Urinalysis would have been an excellent and inexpensive tool to differentiate between intravascular hemolysis or improper blood sampling that might have generated an increased hemolysis index.
  • There were no fundamentals for the suspected benign vacuolar hepatopathy or benign nodules, as all other possible illnesses were never excluded and an abdominal ultrasound examination or liver biopsy, which are the first intent diagnosis tools for liver conditions, were never performed.
  • ***’s owners’ turned to this clinic, trusting that they could receive a well-informed second opinion. Instead, they were advised to self-documentation for what was still an undiagnosed condition. The information on the internet tends to have a general informative character and it would have been impossible for ***’s owners to understand the risks implied by general anesthesia specifically for her condition.

 

On October 12, 2022, *** underwent general anesthesia for dental work procedures (dental extractions). The procedure lasted approximately one hour and forty minutes and consisted of the complete removal of four incisor teeth and one incomplete removal of an incisor tooth due to the inability to access the root with the dental drill.

  • While AAHA states that “increases in the liver enzymes of an otherwise healthy patient are not an absolute reason to avoid anesthesia,” it is necessary also to understand that ***’s actual condition was never fully and thoroughly evaluated. It is also AAHA that clearly states that a “preanesthetic patient evaluation identifies individual risk factors and underlying physiologic challenges that contribute information for development of the anesthetic plan. Factors to be evaluated include the following: History: Identify risk factors, including responses to previous anesthetic events, known medical conditions, and previous adverse drug responses.” In ***’s case, the actual cause of blood work alterations was never investigated by the attending veterinary doctor, and as such, it would have been impossible to properly evaluate anesthetics risk factors if the definite diagnosis was unknown. Also, there was no way of knowing how to adapt the anesthesia protocol appropriately to ***’s condition.
  • The attending veterinary doctor made a high-risk decision to proceed to anesthetize a case clearly suffering from an unknown condition, later resulting in the loss of the patient. A safe and ethical conduit would have been to postpone the dental procedure and schedule *** for further investigations to establish an accurate diagnosis. As mentioned by AAHA, “Risk factors and individual patients’ needs provide a framework for developing individualized patient plans and may indicate the need for additional diagnostic testing or stabilization before anesthesia. Individual practice procedures may include a minimum database of laboratory analysis, electrocardiogram, and diagnostic imaging for different patient groups.”
  • Tranquilizer and sedative selection for general anesthesia pre-medication in liver disease patients present a significant challenge to the anesthetist. In patients with moderate to severe liver disease, some drugs are to be used with caution or avoided entirely as they may have a long duration of effect and may be heavily dependent on the liver for elimination from the body. Other drugs may compromise vital organ blood flow and oxygen delivery, so their use should be limited to animals with mild diseases. Benzodiazepines can exacerbate hepatic problems in patients with liver disease, and their use should be avoided as their sedative qualities may be exaggerated and present for a prolonged duration in a patient with significant liver disease. For ***, the pre-anesthetic protocol included Buprenorphine, Midazolam and Propofol. Midazolam is a sedative and muscle relaxant belonging to the benzodiazepine class, metabolized by the liver. Propofol is a potent sedative and anesthetic drug rapidly metabolized in the liver and other extrahepatic sites. Specialty literature clearly states that “considerable care must be taken with administration in hypovolaemic animals and those with cardiopulmonary, hepatic and renal illnesses.” Buprenorphine, an opioid partial agonist, is also metabolized in the liver, and patients with impaired hepatic function can display a prolonged effect.
  • Pet owners have the right to be clearly informed about any risk involved in general anesthesia, all the more in cases where the patient is suffering from any form of kidney, heart, or liver disease or any other type of illness that may result in death or other definitive or debilitating conditions. In this case, AAHA mentions in the AAHA Anesthesia Guidelines for Dogs and Cats that “Client communication is important at all times, but especially before anesthetic procedures.” and veterinary doctors should “Obtain written informed consent after discussing the patient assessment and risks, the proposed anesthetic plan, and any available medical or surgical alternatives with the client.” In this case, the attending veterinary doctor failed to properly communicate blood work results and risks implied by general anesthesia with ***’s owners and never performed a risk assessment. Also, ***’s owners never signed an informed consent agreeing that even if she was suffering from an unknown condition, they still wanted the dental procedure performed, with all the risks implied.

 

On October 15, 2022, three days following the dental procedure, ***’s clinical state started to deteriorate, and she began vomiting, being anorexic and lethargic. The owners called the hospital to express their concerns, and the only recommendation received from the clinic staff was to discontinue antibiotics.

On October 18, 2022, *** was scheduled for a post-surgical follow-up. Aside from suspicion of icterus, which is an indicator of liver dysfunction or biliary-tract obstruction, physical examination observations were unremarkable. Given this suspicion, the attending veterinary doctor asked ***’s owners if they wished to have blood work repeated, and according to the owner’s statement, they did not suggest in any way that blood work was, in fact, mandatory given the suspicion of icterus. Urinalysis was also performed.

Blood work results indicated:

  • acute kidney injury with a creatinine of 2.9 mg/dL (reference range 0.5 – 1.8 mg/dL) and a blood urea nitrogen of 86 mg/dL (reference range 7 – 27 mg/dL);
  • increased liver enzymes (ALT 158 U/L, reference range 10 – 125 U/L), indicative for liver dysfunction;
  • a severely increased ALP of 1938 U/L (reference range 23 – 212 U/L), revealing an aggravation of the underlying undiagnosed condition;
  • electrolyte imbalances which may have been caused by vomiting or may have also been related to the undiagnosed condition;
  • increased globulin levels (a type of protein). Increased globulins can be associated with dehydration, chronic immune stimulation, neoplasia, or inflammation;
  • abnormal cPL (Canine Pancreatic Lipase), a specific lipase found only in canine pancreatic tissue. This finding was consistent with pancreatitis.

 

Urinalysis results were consistent with a urinary tract infection, as a large number of cocci (bacteria) were detected.

The CBC results indicated an increased level of white blood cells, neutrophils, and monocytes, which were considered a consequence of an infection, specifically pyelonephritis. Specialty literature also links the observed changes to inflammation, neoplasia, and immune-mediated disease. Other CBC observations included decreased eosinophils which may have been consistent with infection.

The attending veterinary doctor noted in the medical file that they had no explanation for the acute organ failure and advised ***’s owners to take her to a 24h emergency facility care.

  • As mentioned previously, persistent increased ALP is associated with numerous severe illnesses, including liver disease, cholestatic conditions, bone disease, endocrine diseases, neoplasia, hyperplasia, and idiopathic disorders. The attending veterinary doctor disregarded essential warning signals and proceeded to general anesthesia and performed dental procedure work, an intervention that was not essential for ***’s well-being at that particular moment.
  • There was a complete disregard for the current guidelines of good clinical practice that state that all patients should be thoroughly evaluated before general anesthesia, which should be postponed if additional investigation procedures are required.
  • Icterus, or the yellow discoloration of mucous membranes or skin, appears secondary to high bilirubin levels accumulated in the blood due to bile duct obstruction, impaired liver function (neoplasia or portosystemic shunt), or red blood cell destruction. Although the physical evaluation noted that *** might have had icterus, bilirubin measurement was not included in the blood work.

 

On the same day, October 18, 2022, *** was taken by her owners to ***, as recommended by Dr. ***. Here, *** underwent additional investigations, including abdominal ultrasound, confirming pancreatitis and received supportive care and specific treatment for pancreatitis, acute kidney failure, and a suspected intestinal ulcer. *** was stabilized and discharged on October 20, 2022, with recommendations for at-home oral medication, including a course of antibiotics and a low-fat diet. *** was doing better and was eating small meals.

On October 21, 2022, ***’s clinical signs relapsed after a brief walk that the veterinary doctor at *** approved. Her owners took her back to the 24h emergency care, where new blood work investigations revealed that her liver enzymes and kidney parameters had increased back to extreme levels. At this point, the clinic staff at *** advised the owners to take *** to a specialized facility. On the same day, *** was admitted for intensive treatment and additional investigations at ***. *** was hospitalized for intensive supportive care, and although her investigations were consistent with marked alterations of blood work parameters, she seemed to improve until October 29, when she was weaker than usual, developed a moderate amount of free fluid in her abdomen and showed signs of regression. The attending veterinary doctor at *** considered abdominal exploratory laparotomy (a surgical intervention for diagnosis purposes, direct examination, and taking biopsy samples of abdominal organs). Post-operatory recovery proved difficult as *** was hypotensive and required norepinephrine (noradrenaline).

On October 30, 2022, 18 days after she was put under general anesthesia for a non-urgent dental procedure, ***’s heart stopped. Despite the efforts performed by the veterinary doctors at ***, she did not respond to the cardio-pulmonary resuscitation procedures. The diagnosis established within *** following all investigations, including the abdominal exploratory laparotomy, included pancreatitis, peripancreatic mass, or abscess causing extrahepatic biliary obstruction. All these conditions were at the root of altered parameters observed since August 2021 and were, without a doubt, aggravated by the general anesthesia and non-urgent dental procedure performed on October 18, 2022, within *** Hospital. If diagnosed in time, while still in a good and stable clinical condition, *** could have been treated successfully, the prognosis would have been different and she would have been able to lead a long and happy life.

To conclude, based on 12 years of clinical veterinary experience, my professional opinion is that ***’s death was, without a doubt, a result of a series of poor decisions the attending veterinary doctor made involving a high degree of risk. Due to negligence or lack of knowledge, the attending veterinary doctor thought very little of ***’s condition and proceeded to put her under general anesthesia even if she was suffering from a clear but undiagnosed condition.

I, ***, DVM, state that there exists a reasonable probability that the care, skill, or knowledge exercised in the treatment, practice, or work that is the subject of the complaint fell outside acceptable professional standards and that such conduct was the cause in bringing about the harm. I also find there to be negligence in failing to disclose known risks fully, complications, and alternatives to the surgery, treatment, and medications.

Considering the acts of malpractice described in the present letter, I believe *** should receive significant damages for financial and emotional losses, including the entire veterinary expenses starting from October 18, 2022, until ***’s passing.

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Apr 12, 2020

Re: *** and my assessment of veterinary medical practice below standard of care and negligence, as well as failure to maintain appropriate medical records.

To whom it may concern:

The following is my assessment of the sequence of clinical events, surrounding the tragic passing of ***, a previously deceased, 7-year-old, approximately 17-pound, male Dachshund, belonging to ***, and who passed from complications from gastrointestinal ulceration and perforation, which resulted in peritonitis, sepsis, and acute kidney failure. It is my STRONG professional opinion, based on 30 years of clinical veterinary experience, that *** was the victim of gross negligence and malpractice, involving inappropriate use of corticosteroids and non-steroidal anti-inflammatory drugs at the same time, as well as negligent medical practice at multiple points of treatment, leading up to the gastrointestinal perforation. There were also totally inadequate medical records on this case at several stages of treatment as well by the primary veterinary care hospital at ***.

In reviewing the quite minimal medical records supplied to me in this case, the evidence of negligent medical practices is obvious as early as June 18, 2019, when *** was treated with both a dexamethasone injection and Rimadyl injection for some sort of acute medical condition (no physical exam or SOAP notes provided by Veterinary Clinic). There is no justifiable and reasonable medical reason why any canine patient should receive treatment with both a strong corticosteroid such as Dexamethasone, and a non-steroidal drug like Rimadyl at the same time, especially with ***’s medical history. On this date, she was also sent home with generic Rimadyl (known as Vetprofen) tablets. I have no idea what *** was being treated for on June 18, 2019, as did not supply any medical records for this date. The concomitant use of both a corticosteroid and non-steroidal anti-inflammatory drug pose severe medical risks to the patient, including gastrointestinal erosion and ulceration, as well as significant immune suppression in any aged patient, even when used short term. This is even more inexcusable with ***’s medical history, as *** was suffering from a chronic autoimmune disease of her colon for 2.5 years, which had been diagnosed in 2017 at by endoscopic biopsy. According to ***, *** had been misdiagnosed and wrongly prescribed medications for “supposed pancreatitis” by at that time in 2017, with a 3-month history of severe, mucousy and bloody stools, which was not responding to treatment for pancreatitis. It was not until the correct diagnosis was made by *** and the appropriate, oral prednisone prescribed, that *** experienced clinical relief of this chronic and incurable autoimmune bowel condition. In fact, at the time of ***’s passing, she had still been on a low maintenance dose of prednisone to control this chronic bowel condition, and so the prescribing of Vetprofen on June 18, 2019, was an early sign of medical negligence and malpractice, given that *** was taking oral prednisone long term.

The next date of medical malpractice in this case is obvious on September 23, 2019. On this date, *** received both a 6 in one vaccination (containing Distemper / Adenovirus / Parainfluenza / Parvovirus / Leptospirosis and Coronavirus), IN ADDITION to her Rabies vaccination on this date. Current standards of practice at all veterinary schools in the country, including ***, recommend not more than once every three years for core viral vaccinations, including Distemper/Parvo combination vaccinations and Rabies. These are recommendations made by immunological experts in veterinary medicine, due to documented long term immunity to these core viral vaccinations, as well as the risks of severe autoimmune or immunosuppressive disease from vaccinating for these core viruses too frequently. It should also be noted that it had only been 10.5 MONTHS since ***’s previous DAPP vaccination, which had been given on November 3, 2018. I should also note that well respected veterinary medicine vaccine experts, such as W. Jean Dodds, DVM, caution that certain small breeds, such as the Dachshund are even more susceptible to immune reactions from over-vaccination. It also says in all vaccine inserts that the vaccinations are to be given to healthy animals only. *** was suffering from a chronic autoimmune bowel condition, and should never have been vaccinated like this, much less only 10 months apart. It is also recommended that in breeds like Dachshunds multiple vaccinations like this not be given on the same day, as it was in this case. I should also note that including the non-core vaccination Leptospirosis in the combination also should have involved a discussion with as to whether this vaccination was appropriate for *** given her lifestyle, as this vaccination is considered by many to be one of the most immunogenic and reactive of the potential vaccinations given to dogs.

The date of these combination vaccinations is important in this case, as only one month late on October 26, 2019, *** re-presented to, for what called a “knot on her back”, which looked like she may have been bitten by something, yet no altercation with another animal or insect bite was directly observed. In the minimal record provided, the only history recorded said, “checking a spot on the back,” at a location where typically one or both vaccinations may have been given a few weeks earlier. As there were no exam notes from the September 23, 2019, exam, we have no idea where the vaccinations were given. Vaccination lump reactions are common in the days and weeks ahead, especially when polyvalent, multiple vaccinations are given at the same time, and especially in the Dachshund breed. There are no physical exams or SOAP notes provided by on this date either on October 26, 2019. There is a receipt for services provided to me, as well as the listing of “Staff Name” at the top of the receipt, which lists the name of, whom I am not sure is a licensed veterinarian, veterinary technician, or other staff member of. On this date, *** was given a Dexamethasone injection and PCN (antibiotic) injection, while being sent home on Amoxicillin at dose of 100 mg twice daily and a topical solution to apply to the spot on her back.

The next service provided by was on November 6, 2019, where it only says “Recheck” in the minimal records provided to me, as well as a “Staff Name” of ***, whom I do not know either, if she is a licensed veterinarian or veterinary nurse/technician. According to there was little change since October 26, 2019, and therefore surgery was scheduled for November 7, 2019, where according to the minimal record provided, it says “Clean/Flush” with listed under “Staff Name” on that date, however it is not clear whether she is the veterinarian that day or not. On that same day, however an “owner release” is signed, where consents and authorizes, DVM to “prescribe for, treat or operate upon” ***. On the receipt that day is listed “tumor removal”, which I can only assume was the mass or lump from a “likely” vaccine reaction, however no surgical notes were provided, or biopsy performed for definitive diagnosis. This also differs from what the medical notes said earlier and later on, where a “brown recluse spider bite” was noted in the record, which certainly is not the same as a tumor? I am confused on who performed the surgery that day, whether did the procedure or, who was legally given consent to operate on ***. I should also note that did not offer pre-surgical blood work, which should have been routine, minimum standard of care diagnostics offered on a 7-year-old Dachshund with ***’s medical history, as well as to see if there were any underlying metabolic causes that *** may have had, and which could have been a cause of delayed wound healing. On the receipt that day on November 7, 2019, there is no anesthetic listed that was used to “remove the tumor,” which is very problematic, both from a medical record keeping perspective, as well as understanding if any anesthetic was used at all? Once again (as done on June 18, 2019, for an unknown condition) *** was given a Dexamethasone injection, Rimadyl injection, as well as the same Penicillin injection (i.e., PCN) that had not worked the first time on October 26, 2019. Once again *** is sent home on generic Rimadyl (i.e Vetprofen) at a dose of 37.5 mg once daily, even though *** is already on maintenance prednisone for her chronic colitis. It is also highly disturbing that NO further antibiotics were dispensed on the surgical date, even though the lesion was getting progressively worse, with no definitive diagnosis, wound culture (which should have been done) or biopsy performed.

According to ***, he heard loud crying coming from ***’s operating room, after which a veterinary employee emerged saying that he could not take *** home, unless he signed a waiver, which was provided to me for review, in preparation for writing this letter. This “Acknowledgement and Waiver Against Medical Advice” lists that *** had elected to take *** home “under anesthetic without proper medical observation.” However, there is nothing listed in the scant records about which, IF ANY anesthetic was used for the “Tumor removal,” or ANY discussion between and the staff at that *** should stay in the clinic longer for her recovery from surgery. The only other record notation from was the following day on November 8, 2019, where it simply lists “Rebandage,” along with the “Staff Name” of listed, who is also not listed as a veterinary technician or doctor, nor are there any notes about the condition of the wound or bandage changing process. According to, after he got *** home from surgery the bandage was falling off with the post op wound full of blood, at which point he had to place the bandage back on himself. He returned to on November 8, 2019, however, never saw the “supposed” veterinary surgeon ***, DVM to discuss his concerns and fears, as *** was taken into the back, where her bandage was changed, and he was told to return in 3 days after the weekend for a next recheck. *** progressively declined over the weekend from November 8 through November 10 with development of severe lethargy, vomiting, poor appetite, and no thirst, while not producing any urine or stool.

Because *** was rapidly failing, took *** to *** at 4:53 PM on November 10, 2019. Evaluation at the ER showed at the distal end of the suture line, that there was evidence of skin necrosis (i.e., dying, black tissue), as well as rapidly developing cellulitis, with serosanguinous discharge located at the surgical site on the left lateral thorax. Initial assessment and blood work showed upper GI bleeding, melena (digested blood in the stool), acute kidney failure, with creatinine of 9.7 (reference range .5 to 1.3), BUN <140 (reference range 10-26), Potassium 7.1 (reference range 3.4-4.9), as well as severe metabolic acidosis with TCO2 of 13 (reference range 17-25). *** also was clearly septic with white blood cell count of over 65,000 (reference range 5000-16000) and significant left shift with bands present. Urine analysis confirmed acute kidney failure damage with ph of 5.0, plus 300 glucoses in the urine, and a urine specific gravity of 1.010. *** was subsequently admitted for intensive ICU level treatment for gastrointestinal bleeding and acute renal failure. On the following day of admission on November 11, 2019, of the Internal Medicine Service was consulted for an abdominal ultrasound, which confirmed a significant peritonitis with a large amount of peritoneal effusion in the abdominal cavity, along with a “corrugated duodenum” on the ultrasound, which he concluded was due to a high GI perforation. *** states in the medical record that “I have a very high index of suspicion for a high GI perforation, given ***’s clinical presentation and HISTORY OF RECEIVING BOTH STEROIDS AND NSAIDS.” *** spent several days at *** until November 14, 2019, where she was discharged on several medications and almost a $4,000 total bill. Unfortunately, over the next several days, *** did very poorly at home, and was subsequently euthanized on November 19, 2019, due to excessive suffering, poor quality of life and extremely poor prognosis of recovery.

In my 30 years of veterinary medical practice, I have never seen a case so mismanaged on so many levels from the outset of this case that I have documented in chronological order in this letter. The areas of negligence, malpractice, as well as practicing below ANY expected minimal standard of care are evident here, in addition to the atrocious and totally unacceptable medical record keeping in this case. In fact, there is only one date in ***’s 2019 medical history provided on February 25, 2019, where there are acceptable SOAP medical notes for *** on that date. However, NO exam or SOAP notes were provided for the dates needed in this case from October 26, 2019, through November 8, 2019, when *** was under ***’s primary care for the bite or tumor.

Following my initial phone discussion with *** on April 8, 2020, I asked him to contact and obtain the appropriate medical records on the relevant dates from October 26, 2019, through November 8, 2019. *** contacted multiple times on April 9, 2020, to obtain the medical records on these dates, at which point an employee named “***” sent a scant email of minimal records. At 1:42 PM on April 9, 2020, spoke to, (who is supposedly wife) spoke to ***, who told that there are usually exam notes, but for some reason they were not put into the computer, and therefore had no additional medical records to provide. According to he was told that there were no exam notes from October 26, 2019 (date of ***’s first presentation for the supposed bite) or from November 7, 2019 (date of the “Tumor Removal” surgery) or November 8, 2019 (one day post op rechecks). According to ***, he informed me that he was told that usually makes SOAP exam notes, but they don’t have them in this case, and did not know why, nor could they provide more information than they already had.

In my strong opinion for the multiple reasons cited throughout this letter, Mr. ***, who should receive significant damages, including the entire veterinary expenses of almost $6,000 post operatively from the date of the surgery on November 7, 2019. I also feel that there was undue emotional damage incurred both with himself, as well as for ***, who was the ultimate victim of negligence, malpractice, and in my opinion, animal abuse. Please let me know if you have any other questions.

***

Nov 26, 2022

PROFESSIONAL CONSULTANCY, ***, D.V.M.

The following details dictate my assessment of a proposed malpractice case concerning Dr. *** who performed a sialocele removal surgery at the *** Clinic on ***, a 4-year-old, male neutered Labrador Retriever canine weighing approximately 72lbs owned by ***.

***’s sialocele removal surgery was performed by *** on September 7, 2022 at the *** Clinic, however due to a recurrent and unresolved swelling at the surgery site described as the right ventrolateral mandibular region, *** was referred to *** where he underwent a second surgery. During this second procedure, it was discovered that a 4 x 4 gauze and a small suture needle were left inside ***’s surgical site and posed as foreign objects which prevented the resolution of the swelling. The medical and surgical management of ***’s visits at both the *** and *** are detailed in the following few paragraphs:

*** initially presented to the *** on July 19, 2022, where a 3cm swelling was noted to be located in the right submandibular region. His case was worked up and on August 26, 2022, a diagnosis of a salivary sialocele was made. *** Clinic recommended removal by a dental specialist. On September 3, 2022, *** again presented to the *** Clinic because the mass had ruptured. The affected area was cleaned and flushed and on September 7, 2022, *** from *** performed the sialocele removal at the ***.

According to Dr. ***’s surgical notes, the surgery was uneventful and the right mandibular and Sublingual salivary glands and associated duct were removed. A penrose drain was placed at the Surgical site to allow drainage of blood/fluid from the area. Each step of the surgical procedure was clearly outlined and the owners were given instructions on post-surgical management and follow-up recommendations.

*** had his first post-surgical recheck on September 12, 2022, where it was documented that his face was still very swollen, and cellulitis was suspected. He was dispensed more antibiotics (Enrofloxacin and Amoxicillin/Clavulanic acid) and pain medication (Carprofen). The penrose drain was removed on September 16, 2022, and the swelling was documented to be better. The notes of the attending veterinarian are as follows:

“Minimal drainage around drain, cleaned openings with chlorhexidine-soaked gauze, transected sutures. Removed drain and performed laser therapy. Swelling decreased by about 50% in size. Ultrasound exam of cheek tissue reveals solid matrix, no pockets of fluid found.”

On September 19, 2022, *** again presented to the *** Clinic because the swelling in his right submandibular region had returned. The attending veterinarian’s notes states as follows:

“R lateral neck is swollen, firm and somewhat well circumscribed over parotid salivary gland. Swelling extends cranially to area around manibular [mandibular] premolars, past midline and midway down the neck. Firm, non-painful and is not hot to the touch. No discharge from incision site or drain removal sites. Assessed swelling with ultraound [ultrasound]. No fluid was detected in any region. Aspirate revealed primarily RBCs, occasional skin cell, non-degenerate neutrophils consistent with peripheral blood and no bacteria. Recommended to leave patient at *** and have Dr. *** assess in AM. Will also contact ***, owner approved.”

The client was advised to hotpack the area as well as continue previously dispensed meds and additional antibiotics (Marbofloxacin) were dispensed.

On October 1, 2022, *** had his first Urgent Care visit at *** and was scheduled for a surgical visit on October 5, 2022. ***’s surgery was performed on Oct 6, 2022, and he was discharged on October 7, 2022. *** recommended that *** have his first post-surgical follow-up approximately 3-5 days post-surgery and sutures removed 10-14 days after the procedure. The following paragraph dictates ***’s case summary at ***:

“*** presented to the *** General Surgery Service on 10/5/2022 for evaluation of a recurrent swelling on his right ventral neck that has been treated previously by his primary veterinarian with surgery and antibiotics. After evaluation of ***’s mass, the decision was made to move forward with a CT scan and surgery. *** underwent general anesthesia for a CT scan and exploratory surgery on 10/6/2022. The CT scan revealed foreign material within his mass. During surgery we removed a small suture needle along with one surgical gauze from within the mass on ***’s neck. His abscess was flushed, a drain was placed, and his incision was closed with stitches. Additionally, a sample of ***’s abscess was submitted for culture. We should have these culture results back within one week. *** did well during surgery and recovered from anesthesia without complication. He is being discharged home to you today for continued supportive care and monitoring as he recovers from surgery. Please see the medication, monitoring, and follow up sections listed below for more information about how to best care for *** at home.”

An analysis of ***’s case reveals an obvious error on the part of *** during his surgical treatment of *** where he accidentally left a 4 x 4 gauze and small suture needle in the tissue. It is not unheard of for surgeons to make this error, however every effort should be made to avoid such mistakes as it can lead to additional unnecessary expenses for the client, unnecessary exposure to anesthesia, patient discomfort and even death. Surgeons should routinely check surgical fields for tools used to perform a task. A recommendation which is usually useful is to count the number of gauze used in the procedure and double check the count prior to closing up wounds to ensure that all have been removed. A surgical assistant can help with this. Suture needles can also be counted as many surgeries require several suture packs be used which can amount to many needles. Foreign materials impair the healing process of wounds and can lead to abscess formation as the body tries to wall off the foreign material. As per the notes and follow-up, the surgical recovery seemed as if it would have gone very well had the foreign objects not been left inside the surgical field since with laser therapy and appropriate medication ***’s swelling and drainage were reduced. This idea is further solidified as ***’s recovery was good after removal of the foreign objects by ***.

In conclusion, it can be said that Dr. *** made an error which led to the patient undergoing an additional unnecessary surgical procedure. While this seems to have purely been a mistake, it can be classified as malpractice and as such, the client should be awarded payment for expenses incurred post the initial surgical attempt by ***.

The opinion supplied in this review is subject to modification if additional information is provided and only for the sole use of the party requesting the opinion. This letter is not for publication without the express permission of the undersigned.

Sincerely,

***, D.V.M.

Nov 9, 2022

The following is my assessment of the clinical events surrounding the case of ***, a 4-year and ***, an Emotional Support Animal belonging to ***. The acts evaluated in the present document took place from *** until ***2022, within ***.

The acts, together with the procedures and administered treatments as performed by ***, and actions that have contributed to or might have caused ***’s death, are explained in detail below:

As stated by the owner and observed in medical files, *** was previously diagnosed with a torn cranial cruciate ligament (ligaments of the knee joint) within ***.

For this condition, on October 21, 2022, the attending veterinary doctor within *** prescribed a non-steroidal anti-inflammatory drug, more specifically, Carprofen 100mg, two tabs per day, for 14 days. It is essential to mention that the owner was not provided with a Client Information Sheet explaining the side effects often associated with nonsteroidal anti-inflammatory drugs and did not inform the owner that ***’s caregiver should cease the treatment in case of adverse reactions.

Some of Carprofen’s most severe side effects include gastrointestinal disturbances, bleeding, and ulcerations. As stated by specialty literature and product insert, Carprofen should be ceased immediately in case these clinical signs occur. Also, Carprofen should not be administered in dehydrated, hypovolemic (low circulating blood volume), hypotensive dogs, or those with gastrointestinal disease or blood clotting abnormalities.

On ***, 2022, *** was taken to the previously mentioned boarding facility by her owner to be accommodated for a period of ten days. At admission, the owner instructed the staff of *** that *** should receive the treatment prescribed by the veterinary doctor working with ***.

On the evening of November 12, while in the boarding facility, *** started showing evident clinical signs of gastrointestinal ulceration or perforation. These clinical signs included vomiting of dark brown gastric contents and diarrhea. The boarding facility was unaware that ***’s clinical manifestations were secondary to the administered treatment and, unfortunately, kept administering Carprofen. It is without a doubt that continuing the treatment with the specified non-steroidal anti-inflammatory drug contributed to the rapid aggravation of ***’s condition and her sudden passing.

On the same evening of November 12, 2022, the boarding facility tried to help *** by giving her an injection of an antacid drug (famotidine, unknown dosage) and antidiarrheal drug (Imodium, unknown dosage), administered by mouth. However, her condition was extremely severe, and she did not respond to the treatment. It is essential to mention that the boarding facility staff within the canine resort does not have medical training, they are not veterinary doctors or technicians, and the owner did not consent to the administered treatment.

On November 13 at around 11:29 am, more than 12 hours after the occurrence of the first clinical signs, *** was taken to an Emergency Veterinary Care facility, more specifically, ***.

While in the hospital, *** underwent clinical and physical evaluation and a series of medical investigations, which included a complete blood count, packed cell volume (PCV, which measures the proportion of red blood cells in a given blood sample), blood biochemistry, thorax and abdomen radiographs and blood gas measurements. The result interpretation concluded that *** developed aspiration pneumonia which, more probably than not, occurred as a result of profuse vomiting.

Aspiration pneumonia is an infectious bacterial pulmonary process that occurs after the abnormal entry and passing through the larynx, trachea, and lung of oral or upper gastrointestinal tract content.

As described by specialty literature, aspiration pneumonia develops in three stages:

1. The first stage
This phase occurs immediately after aspiration and consists of damage to the airways and pulmonary tissue (parenchyma) as a direct result of the nature of the aspirated fluid (i.e., irritant or acidic). This caustic tissue damage triggers the activation
of key modulators of inflammation (cytokines) and other inflammatory mediators. The inflammation leads to cell death/necrosis (type I alveolar cells), bronchiolar (smaller branches of the bronchial tree) constriction, pulmonary hemorrhage, increased mucus production, increased vascular permeability resulting in extravasation of proteins into the pulmonary parenchyma, and pulmonary edema, alveolar (air sacs at the end of the bronchial tree) and lung collapse (atelectasis).

2. The second phase of aspiration pneumonia
This phase begins 4 to 6 hours after aspiration and lasts 12 to 48 hours. The second phase is characterized by the infiltration of white blood cells that fight infections (neutrophils) into the alveoli/air sacs and tissue area in and around the wall of the air sacs (pulmonary interstitium). This inflammatory phase consists of ongoing vascular leakage of proteins with the continued development of high-protein pulmonary edema, neutrophil sequestration and activation, and the release of further proinflammatory modulators. These first two stages constitute aspiration pneumonitis, characterized by inflammation without the secondary development of bacterial infection.

3. The third phase of aspiration pneumonia
This phase involves bacterial growth within the airways and pulmonary parenchyma and infection leading to actual pneumonia. In pneumonia, the standard diagnosis protocol requires the following:

  • SPO2 (blood oxygen level) and arterial blood gas measurement.
  • Chest radiographs.
  • Bronchoalveolar lavage for cytology, bacterial culture, and antimicrobial
    sensitivity.
  • +/- Hematology and blood biochemistry.

Further, standard treatment protocol requires:

  • Treating the underlying condition.
  • Antibiotic therapy should be administered for at least 6 weeks. Antimicrobial drug selection should be based on culture and sensitivity examination results. Clinically stable patients should be treated with two antibiotics, while systemically/severely ill patients require a four-quadrant antibiotic therapy (four different antibiotics);
  • Hypoxemic patients require oxygen supplementation or, in severe cases, mechanical ventilation.
  • Supportive therapy includes IV fluid administration to maintain systemic and
    airway hydration, nebulization with sterile saline solution, coupage, and turning of
    recumbent patients.

With a diagnosis established in due time, the correct treatment and supportive care, patients diagnosed with aspiration pneumonia have a fair to good prognosis with a survival rate of 77% to 82%.

Other diagnoses and conditions included on ***’s problem list as established within *** included:

  1. Gastroenteritis.
  2. Aspiration pneumonia.
  3. Small volume pleural effusion.
  4. Fever.
  5. Metabolic acidosis with respiratory compensation.

The administered treatment while in the Emergency Care facility included:

  1. Hospitalization for supportive care for gastroenteritis & pneumonia.
  2. Intravenous regular fluid administration, including potassium chloride.
  3. Antacids and anti-vomiting drugs.
  4. Nebulization — the patient did not tolerate treatment, so it was discontinued.
  5. Oxygen therapy — administered through a bilateral nasal cannula (10Fr) with 6L/min split between them.
  6. Antibiotic administration — which included:
    • On November 13, 2022 – Metronidazole 10 mg/kg every 12 hr (recommended dose 25 mg/kg by mouth every 12h or 50 mg/kg, by mouth, every 24hr).
    • On November 14, 2022 – Ampicillin + Sulbactam 30mg/ml.
    • On November 15, 2022 – Enrofloxacin 136mg tablet (3.5 tablets) that were administered by mouth once daily.
    • Ampicillin + Sulbactam 30mg/ml.

On November 15, 2022, at around 3 pm, ***’s temperature rose to 106.1°F (reference range 101.0 to 102.5F°), and she went into cardiac arrest. The owner chose not to resuscitate *** and let her pass. *** was not submitted for a necropsy/autopsy
examination and was cremated as the attending veterinary doctor at *** recommended.

It is my opinion that with early intervention and a different approach to the case, *** might have had a chance to recover fully.

I, ***, DVM, state that there exists a reasonable probability that the care, skill, or knowledge exercised in the treatment, practice, or work that is the subject of the complaint fell outside acceptable professional standards and that such conduct was cause in bringing about the harm. I also find there to be negligence in failing to disclose known risks fully, complications, and alternatives to the surgery, treatment, and medications.

Considering the acts of negligence described in the present letter, I believe that *** should receive damages for emotional losses and reimbursement for the entire veterinary expenses. This opinion is subject to modification if additional information is provided and only for the sole use of the party requesting the opinion. This letter is not for publication without the express permission of the undersigned.

Sincerely,
***

Oct 2, 2022

I have reviewed the provided records of ***, a 6 year old Hound Mix belonging to Ms. ***.
 
Based on my 13 years of experience as a veterinary, it is my opinion that Dr. ***, the veterinarian who provided care for *** failed to practice medicine with that level of care, skill and treatment for the following reasons:

  • He did not take into account *** 2-year history of chronic kidney disease.
  • He performed the teeth cleaning procedure without informing the owner of the high values of blood urea nitrogen (BUN) and creatinine (CREA) from the pre-op blood work.
  • He did not attach importance to this aspect even after Ms. *** found out by accident about the high values of her dog’s blood parameters.
  • He did not get in touch with *** even after she contacted him (with numerous phone calls for a week) to talk about *** declining health condition.
  • Ms. *** was told that the treatment with the antibiotic amoxicillin is mandatory even if her dog vomited countless times after its administration.


*** was diagnosed with chronic kidney disease (CKD) on 09/16/2020. His blood urea nitrogen and creatinine values were above the normal physiological limits as follows: BUN = 139 (reference range: 6-31 mg/dL) CREA = 13.1 (reference range: 0.5-1.6 mg/dL)

  •  

For two years, with the help of treatment and Mrs. *** perseverance and love, *** started to feel better and his biochemical blood values improved:

90/21/2020 – CREA = 7.8 mg/dL; BUN = 90 mg/dL

09/23/2020 – CREA = 6.6 mg/dL; BUN = 129 mg/dL

09/26/2020 – CREA = 6.8 mg/dL; BUN = 113 mg/dL

10/5/2020 – CREA = 5.2 mg/dL; BUN = 44 mg/dL

10/27/2020 – CREA = 3.6 mg/dL; BUN = 49 mg/dL

01/02/2021 – CREA = 3.6 mg/dL; BUN = 47 mg/dL

07/02/2021 – CREA = 2.9 mg/dL; BUN = 35 mg/dL

One year after the last biochemical blood analysis, Dr. *** scheduled *** for teeth cleaning, which included general anesthesia.

Administration of general anesthesia can induce a reduction in renal blood flow in some patients. If a patient already has damaged kidneys (as is the case with ***), the renal function will be even more limited.

On 07/21/2022, the pre-operative/pre-anesthetic blood profile (PAP) analyses highlighted: CREA = 5.9 mg/dL; BUN = 83 mg/dL; GLI = 137 mg/dL.

Dr. *** failed to notify Mrs. *** about the values of the PAP test and performed the teeth cleaning under general anesthesia. Mrs. *** found out about the elevated blood test values by accident.

After the dental procedure, *** health began to deteriorate, and Ms. *** tried numerous times to speak with Dr. *** to examine *** and administer the proper treatment.

Ms. *** wanted to administer *** subcutaneous treatment (Ringer lactate) as she did in the past to help him lower those high numbers but Dr. Dick didn’t call back.

Ten days after the teeth cleaning (01/08/2022), ***’s BUN and CREA values were 169 mg/dL and 15.6 mg/dL, respectively (three times higher than at the time of the dental procedure). On 08/03/2022, the values of BUN and CREA were even higher: 180 mg/dL and 20 mg/dL, respectively.

It should be noted that *** was diagnosed with CKD and had his teeth cleaned at the same hospital, ***.

On 07/08/2022, Ms. *** arrived with *** in an emergency at another veterinary practice ***. Following the examination and laboratory tests, the following were concluded by the ER doctor: renal failure, uremic syndrome, metabolic acidosis, anemia, heart murmur, hypertension, and lymphadenopathy.

The values of creatinine and blood urea nitrogen were: CREA = 20.6 mg/dl, BUN = 176 mg/dL, values that put his life in danger.

With treatment, ***’s condition started to improve, and on 08/10/2022, Mrs. *** even managed to take him out for short walks.

Unfortunately, in two days (10/08/2022), ***’s health declined rapidly, and Ms. *** had to euthanize her dog about two weeks after the dental procedure.

From my point of view, the teeth cleaning procedure should not have been performed. The values of the renal parameters were not within normal physiological limits, but four times higher for creatinine and three times higher for blood urea nitrogen. Not to mention the fact that *** also had a two-year history of chronic kidney disease.


With ***’s health history, a procedure with general anesthesia should only have been performed as a last resort to try to save his life, not for a dental procedure.

Also, insisting on administering amoxicillin when the dog vomits several times after taking it is problematic; other treatments could have been tried. Like most antibiotics, amoxicillin can irritate the stomach. *** already had an irritated stomach due to high levels of blood urea nitrogen and creatinine, and amoxicillin took on an already irritated and empty stomach (as he wouldn’t eat), led to vomiting.

This opinion is subject to modification if additional information is provided and only for the sole use of the party requesting the opinion. This letter is not for publication without the express permission of the undersigned.

***, DVM