THIS series gives readers the opportunity to consider and contribute to discussion of some of the ethical dilemmas that can arise in veterinary practice. Each month, a case scenario is presented, followed by discussion of some of the issues involved.
In addition, a possible way forward is suggested; however, there is rarely a cut-and-dried answer in such cases, and readers may wish to suggest an alternative approach. This month's dilemma, ‘Accounting for a lame cow’, was submitted and is discussed by Richard Brown. Readers with comments to contribute are invited to send them as soon as possible, so that they can be considered for publication in the next issue. Discussion of the dilemma ‘“Off colour” alpaca’, which was published in the September issue of In Practice, appears on page 487.
The series is being coordinated by Siobhan Mullan, of the University of Bristol. It is hoped it will provide a framework that will help practices find solutions when facing similar dilemmas.
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Richard Brown qualified from the University of Cambridge in 1981. He gained an MSc in tropical veterinary medicine from the Royal (Dick) School of Veterinary Studies in 1986. He has served as a veterinarian with various overseas governments and has practised for over 20 years in the UK. He is currently an associate director at the School of Veterinary Medicine at City University in Hong Kong.
Accounting for a lame cow
A farmer's wife wants to clear the farm account before year's end, as is her custom. After signing the cheque, she pulls out some of the last few months' accounts and asks to speak to you, the senior partner, as she can't understand why the last two months' bills have been so high. She knows the average bill per month is about £500, or a little over, and that this can almost halve or double depending on the time of year, but the bills for November and December had run at about twice what she would expect.
Together with the farmer's wife, you examine the recent accounts and compare them with your own computer data (Ringrose and others 2009). The average vet bill (preventive medicine, medicines and time) per suckler cow per year is about £50, and as they have 140 cows, the annual bill per year is £7000, £583 per month. November and December are usually average months, around £500, but this year they have both been over £1000. On close examination, you realise that although there has been one bad calving, one single item stands out: total expenditure on treating a pedigree embryo donor cow has exceeded £1400.
In October, the cow, which was dry, suddenly went lame., The farmer treated her for five days himself using non-steroidal analgesics and tetracyclines: this produced a mediocre response. On day six, your colleague discovered that the hock had probably suffered trauma and there was a small discharging wound . His treatment involved supporting the limb with a partial cast, flushing the wound and changing the antibiotic. Then the case had taken on a ‘ mission creep’ of repeated examinations and treatments and three different vets attending. Slight improvements were seen which encouraged continuing therapy but produced no absolute cure. The cow is still significantly lame and is only insured for death, not for loss of use. What do you say to the farmer's wife, what advice do you give her and what are the welfare implications of what has happened?
Issues to consider
You need to train all your staff to be aware that unexpected spending by clients of large sums may indicate a possible unresolved problem with welfare implications.
While the cow can probably still be used as an embryo donor if using NSAIDs, she cannot stand to service if lame. The lameness may mean that fewer embryos are harvested; this hints that the priority is to try to cure her. Undoubtedly, you will have to visit the farm and use all your skills as a clinician, a diplomat and business person. But using the cow's welfare as the priority may be the best way to cut this Gordian knot.
At first sight, there appear to have been faults on both the sides. But one must be aware: hindsight always provides 20:20 vision. Every person may have acted correctly on the day they did a piece of work. It is important that from now on both husband and wife are involved as one unit in future discussions, without there being any attempt to apportion blame.
You should consider phoning your own insurers after the farmer's wife has left. You may not be able to manage this case yourself, so the insurers should be involved early on. Usually insurers understand that your best defence is to make the welfare of the cow a priority. Thus, you will probably discuss in detail before and after clinically examining the cow the five most likely options: referral to a centre of excellence, seeking a second opinion, treating the cow yourself, salvage slaughter, or euthanasia.
In this case, you may be about to lose a client but you have to bear in mind your priority is the welfare needs of the cow.
Possible way forward
As senior partner you will have to attend to three things: the treatment of the cow; gathering information as to exactly what has occurred; and reporting back to your colleagues, insurers, and the farmer and his wife about what has happened. You should make it clear to all these parties that this is what you are about to do as soon as you can.
It is possible you will decide that the cow should be transferred to a centre of excellence (eg, a university veterinary school) for an accurate diagnosis and treatment. Although a movement to a veterinary clinic under current legislation (Defra 2012) is exempt from the transport restrictions based on welfare grounds, one should be attentive to the spirit of the law. If the cow is to be transported, it should be inspected by a vet on the day of transfer and the receiving centre should have been fully informed before and agreed. The inside of the float should be well bedded and the cow should be sent in a single float. However, it may be too lame to transfer if the centre is far away, or the farmer is unwilling to pay the potential fees and your insurers willing to defend your position and not offer any financial assistance.
If you decide that the practice should treat the cow then you should satisfy yourself that this plan is acceptable from a welfare viewpoint and you have a reasonable chance of success.
If you think euthanasia is the best option then that would usually suggest that the situation is so serious that you cannot, on welfare grounds, wait for the drug withdrawal times required for salvage slaughter. The cow is a total loss. It is possible that at that point the farmer will insist on a second opinion. It is the farmers decision as to who he calls, but often one can suggest two or three names for him to choose from. You will have to give the referring vet as much information as the vet needs but you would be well advised to give them your view of the matters relevant to the cow's present welfare. You will have to keep records.
If you are able to solve the problem amicably, afterwards you should set up an agreed protocol with the farmer taking into account welfare. For example, the farmer has to contact the vet if he has treated an animal for 48 hours with poor response; for certain conditions the time should be shortened, eg, a dyspnoeic beast. Encourage the farmer to phone for advice; this is usually free. Many farms are members of farm assurance schemes which possess a welfare element. If so, this is an opportunity to incorporate these new ideas into the welfare plan, and this can be written down in some detail.
Finally, if you, as senior partner, were not aware of these events as they built up, you need to set up protocols to stop recurrence, for your own welfare.
Readers with views to contribute on ‘Accounting for a lame cow’ should e-mail them to firstname.lastname@example.org so that they can be considered for publication in the next issue. The deadline for receipt of comments is Friday, October 30. Please limit contributions to 200 words.
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