Thursday, May 31, 2012

Cheaper does not equal better

"Patient presents for a routine spay."  -- This might seem like an simple, straightforward statement, but it couldn't be more of a complicated issue.

There is no such thing as a routine spay - each and every ovariohysterectomy (the medical term for removal of the ovaries and uterus) is a complicated, in depth surgical procedure requiring vast knowledge of anatomy, surgical skills, anesthetic monitoring, and careful tissue handling.  Most daytime veterinarians (at regular veterinary clinics, not emergency clinics) perform thousands of these procedures every year, making the procedure itself seem benign - but buyer beware - sometimes you get what you pay for.

Last week, a patient presented to me after experiencing an arrest under anesthesia during a spay.  The patient was a previously healthy, 5 year old miniature pincher named Suzie.  Suzie had been spayed at a local low cost clinic.

Before we discuss Suzie's case  -- what are low cost clinics?
 Low cost clinics are of several varieties; they can either be privately owned and for profit, or run by a government organization such as animal control or a humane society.  Each low cost clinic is different, but in general, they attempt to serve the same purpose - providing spay and neuter surgeries at a deeply discounted price.  This is with the goal of preventing the overpopulation and subsequent euthanasia of unwanted pets. In general, in order to keep overhead at a minimum, these low cost clinics do not have equivalent monitoring equipment, facilities, or staff of a fully modern hospital (of course, this depends on the specific location).  In order to remain "low cost" and charge clients significantly less than the market rate of this major abdominal surgery (the spay), these facilities either have outside funding (eg., governmental grants, private donors, or trust funds), or they are forced to cut corners to save money and pass the savings on to their clients.  Sometimes this means choosing the least expensive (not necessarily the best or safest) form of anesthesia, and sometimes this means that pets receive little to no anesthetic monitoring during their procedure.

Low cost clinics have an important place in our society to help control the pet population.  The vast majority of these facilities are run by truly wonderful people who honestly DO care about doing the right thing for pets.  The problem for me is when the client doesn't know the differences between a 'low cost' spay and a spay at their regular veterinarian - or when they believe the only difference is the dollars and cents.  This isn't the case.  Modern, up to date facilities provide clients with the option of pre-anesthetic blood testing, IV fluids, IV catheter (for emergency use), blood pressure monitoring, ECG, and other vital parameters.  Up-to-date facilities typically have a dedicated assistant or licensed technician who has the exclusive job of monitoring patient parameters and notifying the veterinarian if anything is amiss.  Even without 'fancy' equipment, just a human with training monitoring simple vitals such as heart rate, mucous membrane color, respiratory rate can go a long way in preventing tragedy.   Low cost clinics typically have the pressure of performing as many procedures as possible in a day, as their profit margin is exceptionally low per case. 

Back to Suzie.

Suzie was anesthetized with medications commonly used in low cost facilities, and she received appropriate dosages.  She was intubated and at the time of opening her abdomen, the veterinarian noticed that her heartbeat had stopped.  She was given emergency drugs (atropine and epinephrine), but as no IV catheter was placed, these were given via other less immediately effective routes.  The veterinarian continued the spay, and no IV fluids were given -also due to lack of prior IV catheter placement.

Upon finishing anesthesia, Suzie suffered several seizures, likely from cerebral edema (swelling of her brain) and anoxia (lack of oxygen) during her arrest.  She was transferred, comatose, to our intensive care unit, where she is making a slow, but steady improvement after receiving medications for cerebral edema.  Her prognosis is uncertain, but with time, she may experience a full recovery, at the cost of several thousand dollars and days in the hospital.

How could this have been prevented?
  This is a very difficult question, as the cause of the arrest was not made certain (due to lack of monitoring, trends could not be observed to determine the cause).  Absolutely, an inexpensive safety measure is placing IV catheters in any patient undergoing general anesthesia; if an adverse event does occur, intravenous access is immediately available for life saving fluids and medications. Better yet, monitoring of blood pressure and depth of anesthesia can help the veterinarian and medical team to realize problems BEFORE they result in an arrest, which has a significantly improved prognosis for survival.

Please realize that complications are a part of any surgical procedure (yes, even in human medicine!), and even with perfect technique, monitoring and surgical skills, there is still a small percentage of patients who will experience some problem (ranging from very minor to very serious). The majority of patients do well during spay/neuter procedures despite the lack of cutting edge medicine. In no way do I mean to disparage low cost facilities - they serve a very important purpose - I only wish for the client (and my readers) to have the opportunity to be educated about the differences and make an informed decision. Additionally, pet-owners should feel adequately informed about ANY medical procedure, regardless of the status of the clinic. Ask questions!

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