Colorado Vet Matthew Aaronian: Misdiagnosis; Unnecessary Procedure; and Refusal to Release Animal to Owner Due to an Unpaid Bill, and Maybe Worse

Colorado is one of those states where the veterinary board says lots of nothing in its written decisions. They give very little indication of what happened to the animal as a result of the actions described. But reading between the lines, the "Stipulated Letter of Admonition" issued to Colorado Springs vet Matthew Aaronian raises HUGE RED FLAGS. Let me tell you what is in this document and how I interpret it.

This document, dated March 26, 2007, says:

". . . the Board determined . . . [that] you failed to meet the generally accepted standards of the practice when you misdiagnosed a condition and performed a procedure that was medically unnecessary . . . . The Board also found that you violated C.R.S. sections 12-64-120(1) and (2) when you withheld records from the animals owner because the owner had an outstanding bill. Finally, the Board found that your policy of deeming an animal abandoned if a bill remains upaid for seven days violates C.R.S. section 12-64-115, and that you failed to give proper notice of your intent to deem the animal abandoned as required by C.R.S. section 12-64-115. The Board found that these facts comprised evidence of violations of the practice act . . . the Board hereby admonishes you . . . "

The Board hereby admonishes you????? Is that IT?

Oh, not quite. They ordered him to "complete six hours of POVMR approved continuing education in radiographs, specifically in acute abdomen diagnosis and treatment . . . "

Uh oh. Let's do some reading between the lines, shall we?

We have a reference to a misdiagnosis.

We have a reference to an "unnecessary procedure" -- probably surgery.

We have an order to take training in acute abdomen diagnosis and treatment and radiographs (x-rays).

Reading between the lines, I'm betting that this vet opened up the pet's abdomen based on a misdiagnosis and that it had something to do either misinterpreting x-rays or not taking them at all.

Then, we have reference to an unpaid bill. (Probably for the UNNECESSARY "PROCEDURE").

The Board also says that the vet deemed the "animal abandoned" because the bill (which included charges for the UNNECESSARY SURGERY, I'm betting) went unpaid seven days. It also says that Aaronian failed to give the owners [proper] notice that he was going to consider their animal abandoned, and that he refused to release the records.

Not a good sign, folks.

With respect to abandoned animals, the Colorado Veterinary Practice Act says:

"(1) Any animal placed in the custody of a licensed veterinarian for treatment, boarding, or other care which is unclaimed by its owner or his agent for a period of more than ten days after written notice, by certified mail, return receipt requested, is given to the addressee only at his last known address shall bedeemed to be abandoned and may be turned over to the nearest humane society or animal shelter or disposed of as such custodian may deem proper."

Dispose of, folks, I'm thinking means KILL.

But you see, it seems this animal wasn't abandoned at all. The vet never gave "proper" notice to the owner that he was going to consider the animal abandoned because of the unpaid bill or portion thereof which seemingly included costs for an UNNECESSARY PROCEDURE (presumably, surgery).

So, I'm betting that what happened in this story is that this veterinarian euthanized this animal after having performed unnecessary surgery on it . . . because he was PUNISHING the owners for not paying their bill or for not paying it in its entirety including costs for UNNECESSARY SURGERY RESULTING FROM HIS MISDIAGNOSIS -- that's my conjecture. Reading between the lines, that is what I am led to conclude. If you know different, you just let me know.

This is what I mean about having to read between the lines of these documents, and I always assume the worst.

Links:

Click to go to Colorado Regulatory Agency Website

Better yet, read for yourself right here:





UPDATE! ALERT!!!

Since I doubt there are two Matthew Aaronian vets (although it could be possible), I am pretty sure this is a picture of him. He's on the left.

Here is another, probably earlier one.

If you are living in CALIFORNIA, memorize that face, and if you see him, I'm advising you to take your pet and run fast and far in the opposite direction. These vets who get disciplined in one state seem to have a habit of moving to another, and it seems Aaronian is no different: There is now a Matthew Aaronian practising in Atascadero, CA.

He also seems to have applied for (and been granted) a license to work as a vet supporting the Iditarod in Alaska in 2007. Stellar event that was to be associated with. During that race, one of the "mushers" (Ramy Brooks) was disqualified for hitting his dogs with stakes. One of that man's dogs died and two other dogs died. (Just FYI, three dogs also died in the 2008 Iditarod.

Well, Aaronian affiliating himself with that event is not surprising, is it?

For more on the Iditarod, visit www.helpsleddogs.org.

Unless of course, there is more than 1 veterinarian named Matthew Aaronian. Nah . . . how likely is that?

-- Stefani Olsen

Dr. Derrick Nelson's "Inadequate" and Substandard Treatment of "Jilly" Results in Nothing More than An Informal Reprimand (Texas)

Yet another astounding, devastating case from Texas which results in nothing but an "informal" reprimand from the Texas Veterinary Board.

In 2004, the owner of "Jilly", a Pekinese, noticed that she had been vomiting, she wasn't eating, and she seemed to have jaw pain. She took Jilly to the Animal Clinic of LaPorte, Texas, where Jilly was "treated," if you can call it that, by Derrick Nelson, D.V.M.

When Nelson examined Jilly, he decided that she had severe dental disease. He suggested that Jilly have surgery to remove "the tooth" (it says "the tooth" as though there was one tooth primarily in question) and any other "bad teeth, [clean the remaining teeth, and coat the teeth with a substance that would help prevent
decay."

During the surgery, Nelson removed 13 teeth. The document says that "He noted that the dog's jaw was somewhat loose." Dr. Nelson told Jilly's owner that she was recovering well.

So, later in the day, Jilly's owner came to pick her up. When Jilly was discharged, her owner was given an antibiotic and painkiller (butorphanol). THE BOTTLE SAID THAT JILLY SHOULD BE GIVEN 2 ml every 12 hours.
The board document said that Jilly's owner was told by her sister-in-law who WAS AN EMPLOYEE OF THE CLINIC that "it would be okay to give [Jilly] 1 ml every six hours but not more than 2 ml in 12 hours."

Once home, Jilly wouldn't eat and was vomiting. The next day, Jilly was "weak and lethargic." She had vomiting and diarrhea. Jilly's owner gave Jilly the dose of painkiller. The next day, Jilly was "unresponsive" and had diarrhea and vomiting. Jilly's owner called the clinic, and was told by a technician that "the painkiller dose of 1 ml every 6 hours was too much." But the BOTTLE ITSELF IN FACT SAID THAT JILLY's OWNER SHOULD BE GIVING HER 2 ml EVERY 12 HOURS.

Then, Jilly's owner brought Jilly back to the clinic, where Dr. Nelson told her that the "dosage amount on the painkiller bottle(2 ml by mouth twice daily) was a mis-communication."

Ummm, how can it be a miscommunication? THE BOTTLE SAID THAT, IN TEXT, RIGHT ON THE BOTTLE?

MISCOMMUNICATION MY ASS. The instructions given to this owner in writing on the bottle told the owner to GIVE AN OVERDOSE TO HER DOG.

The document says that "Dr. Nelson believed that the patient was 3-4% dehydrated and administered subcutaneous (SQ) fluids (50 ml LR solution)." The board document SAYS that Jilly was "force fed" and that "Dr. Nelson saw her walk around during the afternoon."

[Do you believe that? I don't!]

Later, Jilly was allowed to go home. But when her owner got her there, she was still vomiting, and still had diarrhea. Worse, she was "shaking and unresponsive."

Jilly's owner's daughter called Dr. Nelson to tell him of Jilly's condition.

Jilly's owner "then decided to take Jilly to the emergency clinic, but before she could do so, the dog died."

The Board said that: "On presentation . . . the patient was clinically dehydrated, at least 6-8 percent. Dr. Nelson's administration of 50 ml of fluids SQ to the patient over a six-hour period was inadequate to address the dehydration. The dog should ahve been placed on IV fluids and monitored closely based on the following, in addition to the dehydration: (a) the dog's age (14) demanded a greater degree of therapy; (b) the patient had a history of recent vomiting, diarrhea, and not eating, and an inability to metabolize and excrete pain medication;" [which, they neglect to emphasize, she had been getting REPEATED OVERDOSES OF thanks to the instructions clearly printed on the bottle -- you know, those little words in black and white that Nelson calls a "miscommunication?"] ". . . and (c) the patient had recently undergone major dental surgery. Dr. Nelson did not determine during the day if the fluid therapy was effective, except to observe that the dog was walking around."

[OH PUHLEASSE!! WALKING AROUND MY A*%!]

The board said that "Dr. Nelson's actions or ination does not represent the same degree of humane skill, and diligence in treating patients as is ordinarily used . . ."

They found that Dr. Nelson violated the Professional Standard of Humane Treatment.

And then they hit him with a whopping disciplinary action . . . a mere informal reprimand.

Wow, bet he learned his lesson.

New York Vet Shawn Michael Demmerle and the Use of Unlicensed Staff to Administer Medications

Those of you familiar with my own case will know that my cat was given an insulin overdose by an unlicensed, unsupervised person. (See my website The Toonces Project for details.) I have a special interest in the dangerous and seemingly widespread practice of veterinarians using individuals who are not qualified (based on veterinary regulations) to perform veterinary duties requiring clinical skill. Worse yet, many veterinarians allow these individuals -- who are unlicensed veterinary assistants -- to perform these duties unsupervised.

This is very dangerous, and that is the reason why I take seriously any cNomplaint or judgment about a vet allowing unlicensed assistants to perform veterinary duties that should only be done by properly trained, certified, staff.

In New York, the Division of Professional Licensing issued the following "Specifications of Professional Misconduct" against veterinarian Shawn Demmerle:

"On or about November, 2004, while employed as a veterinarian by the Sullivan County, New York SPCA in Rock Hill, New York, [Demmerle] permitted an unlicensed person know as 'Tammy' to administer rabies vaccines, an activity requiring a veterinary medicine license, to several animals."

Like many board documents this one does not mention whether any harm came the animals as a result of this. However, a complaint was filed --- and usually some negative consequence must occur to inspire the filing of a complaint.

What could happen?

Well, an inadequately qualified person could draw up the wrong dose, causing an overdose that could seriously injur or even kill a pet. Or, an inadequately trained and unqualified person could fail to recognize symptoms of a adverse reaction in the animal, which in turn could also lead to serious health consequences and even death. (An example of this is the case of Kodi the Pug.)

In his 2006 press release, veterinarian John Robb of the “Protect the Pets” website warned that unlicensed staff performing duties that should only be performed by licensed veterinary technicians or veterinarians themselves poses a grave risk, which can lead to "tragic injury or even death of our beloved pets.”

He went on to add: "I have witnessed first hand horrific examples . . . Soap solution was accidentally placed in the eyes of pets scheduled for surgery, resulting in the sloughing of the surface layers of their corneas. Or urine being mistaken for a drug and being injected into the intravenous line of a pet."

So, this kind of thing can be a very big deal, and a life-endangering practice.

In the case of New York Vet Demmerle, the Professional Licensing Board suspended Demmerle's license for 1 year, but stayed the entire suspension (that is, it was not enforced); instead they placed his license on probation for 1 year and ordered him to pay a fine of $2,000.

Vets Behaving Badly: Pennsylvania Veterinarian Opens Fire in Church, Witnesses Say,

News sources report that Pennsylvania (Lehigh Valley) veterinarian opened fire at a church fundraiser this month. George is reportedly one of 32 shareholders at Valley Central, a veterinary referral service in Lehigh County. He is now charged with 1st degree murder.

According to news reports, "George was heavily armed when he opened fire killing Malak Michael."

Links:

Read and watch local news story online

Long List of Violations Results in Nothing More than a Reprimand and Probation for Virginia Vet, Mitzi Elliot

In March of 2008, the Virginia Board of Veterinary Medicine issued an order to Virginia Veterinarian Mitzi D. Elliot of "The Animal House Veterinary Clinic" in Laurel Fork, Virginia. In this document, the Board stated the following findings of fact (my commentary appears in brackets and italics).

1. A cat named "Kitty" was brought to Dr. Elliot for a routine spay. "To sedate Kitty, a "Push-Pole" was utilized, and Kitty was given an intramuscular injection." [Push pole??? Are they talking about those things they use on animal planet rescue shows called "catch poles?" Like this?? Or are they talking about these push pole things for pushing boats and catching fish?? Either way, a bit mideivel, don't you think?]

The day after Dr. Elliot did these things, ". . . Kitty could not walk on her right hind leg, and was returned to Dr. Elliot's office for an evaluation. Dr. Elliot diagnosed Kitty with a large right lymph node, and prescribed antibiotics. When Kitty failed to improve [Kitty's owner] sought a second opinion from another veterinarian who amputated Kitty's leg. Dr. Elliott failed to take proper precautions administering an intramuscular injection, resulting in damage to Kitty's sciatic nerve."

[OK, did you catch that part about the cat's leg being amputated? I am assuming that the need for this amputation RESULTED FROM the damage caused to Kitty's sciatic nerve as a result of Dr. Elliot's bad vettery. THIS POOR CAT LOST ITS LEG!]

3. "Dr. Elliott failed to document all pertinent medical data in Kitty's medical record. Specifically, Dr. Elliott failed to describe the surgery performed, the diagnosis and/or prognosis, post-operative instructions and treatment recommendations. Additionally . . . Dr. Elliott failed to document patient temperature during the course of treatment."

But Dr. Elliott's bad vettery wasn't restricted to the Kitty incident. The Board goes on:

"4. Dr. Elliott failed to maintain treatment records for the animals brought to her practice. By her own admission, Dr. Elliott sent [two other client's] original records to subsequent veterinarians and did not maintain copies." [Really? Or perhaps the records never existed, were never created, and that's just what she said to play it off as though she had created them in the first place and to explain why she didn't have them?] "Further, Dr. Elliott stated to the inspector for the Department of Health Professions, that she were [sic] not aware of the requirement to maintain records for three years."

5. ". . . [another client] presented with 'Sugar' and 'Daisy', both canines, following a routine spay performed at Dr. Elliott's practice. . . . Both dogs had chewed through their stitches. Dr. Elliott replaced the stitches with staples, but failed to document the type and amount of anesthesia used for placing the staples. Further the records for Daisy did not indicate if an antibiotic was administered and the amoung given."

[OK, the board would not know about this if a complaint had not been filed. Why would the owner file a complaint? SOMETHING must have gone wrong after the surgery. Given the reference to Elliott NOT documenting the kind or amount of anesthesia, I am betting something very bad happened with one or both of these dogs -- I suspect that one may even have died. You see, the Board's don't always tell you what happened to the animals, so you must ALWAYS ASSUME THE WORST.]

6. "Dr. Elliott failed to provide complete records for [yet another client's] canine 'Angel Baby.' Dr. Elliott's records did not include the date of Angel Baby's rabies innoculation and ex-rays taken."

[Geez, we are establishing quite a prolonged and consistent pattern of bad vettery here, aren't we?]

7. YET ANOTHER CLIENT: ". . . presented with 'Prince,' a canine, who had been in an altercatoin with another dog. Prince was admitted with multiple abdominal puncture wounds and shock. When Prince failed to improve . . . [the client] transferred Prince to another veterinarian who found several deep puncture wounds that were not treated; a deep necrotic tract extending dorsally through deep layers of tissue into the sub lumbar region in the retroperitoneal area; and a 3 cm abdominal tear."

[OK, don't worry -- I don't understand all of that either, so I googled some of the words. The "deep necrotic tract" business means that Prince had lots of dead tissue on his lower back going deep into his flesh, into the "peritoneum" which covers the abdominal cavity . . .]

"Further, the veterinarian opined that the Penrose drain that Dr. Elliott inserted may have been improperly placed, which allowed continued saturation of bacteria into the internal wounds. Dr. Elliott failed to properly evaluate, diagnose, and treat Prince's injuries."

[Again, the don't say what happened to Prince, but it sounds VERY grave. I am assuming he DIED.]

8. "Dr. Elliott failed to document all pertinent medical data in Prince's medical record. Specifically, Dr. Elliott failed to describe the surgery performed, the diagnosis and/or prognosis, and treatment recommendations."

[Gee, big surprise. What would that prognosis sound like? Maybe: "Well, I did a totally incompetent job and now this patient had infection deep into his body so -- whoopsie! Where's the pink juice?"]

Whew! After that LITANY of horrors what do we have?

The Board determined that Elliott had committed SEVEN violations of regulation VAC 150-20-140(6) and (7), which is the UNPROFESSIONAL CONDUCT section, including (emphasis mine): "Practising veterinary medicine in such a manner as to ENDANGER the health and welfare of his patients or the public, or being unable to practice veterinary medicine with reasonable skill and safety."

Also they found that she had committed FIVE violations of 18-VAC-150-20-195, which is the regulation pertaining to recordkeeping. (See what I mean when I say that when you see a record-keeping violation, it usually means that something much worse happened.)

After all that you would expect the Board to take pretty strong action, wouldn't you?

Well, guess what?

They reprimanded her.

They put her on "probation" for 18 months but the only terms of the probation were:

a) to take 3 hours of continuing education in record-keeping and 10 hours in patient communication and practice management. NOTHING in improving her skills in clinical care -- her basic veterinary skills. Nothing to improve her competence at actually doing procedures. As though what happened to these animals was all a result of communication problems? Um, did they forget the part about the leg amputation and the internal infection?


b) to have 3 inspections in which they will look at her records and pay the $200 cost of the inspections.

That's it, folks. They didn't give this vet a "time out." Not one day of work missed. No suspension. No big fines. Not even any classes that would improve her clinical skills -- just classes that in my view, are aimed at helping her learn to cover her butt when her lousy clinical skills hurt patients.

Links:

Board Disciplinary Action Against Mitzi Elliott

Death of a Donor Cat in Hands of Colorado Vet Heather Steyn

On April 16, 2007, the Colorado Board of Veterinary Medicine issued a "Stipulated Letter of Admonition" to veterinarian Heather Steyn, DVM, of VCA Ft. Collins Animal Hospital. This letter says (emphasis mine):

" . . .the Board determined that the blood collection practice in this case, which resulted in the death of the donor feline, was substandard. The Board found that your substandard treatment constituted a violation of the practice act. Specifically, the Board hereby admonishes you for a violation of C.R.S. section 12-64-111(1)(l)."

So, the substandard method of blood collection from this case RESULTED IN it's death -- that is clearly stated by the Board. (Boards so rarely establish causation, that I feel that is important to point out.)

C.R.S. section 12-64-111(1) is:

"l) Unprofessional or unethical conduct or engaging in practices in
connection with the practice of veterinary medicine which that are in
violation of the standards of professional conduct generally accepted
standards of veterinary practice as defined in this article or
prescribed by the rules and regulations of the board;"


The Board fined Steyn $500 and ordered her to take 6 hours of education in remedial critical care, but considered the latter requirement satisfied by classes she had already taken. (???) They ordered her to write a three- to five-page paper on blood collection practices.

A web search on Heather Steyn's name indicates that she is actually the MEDICAL DIRECTOR of the VCA Ft. Collins in Fort Collins, Colorado. Just this month she was
offering discounted services on services including semen collection, evaluation and freezing.

So here is my question, if the MEDICAL DIRECTOR is engaging in violations of regulations against "unprofessional" or "unethical" conduct or that which is "a violation of the standards of professional conduct" then . . . what can you expect from the rest of the staff?

Poor, poor donor kitty. R.I.P.

Links:

To see the disciplinary document for yourself,

1. Go to the

Colorado Department of Regulatory Agencies website;
2. Select "Division of Registrations Board/Program Action Documents;
3. Click Logon
4. In the drop-down box on the next page, select: "REG Licensing Board"
5. In the drop-down box on the next page, where is says: "State Board of" - select "Veterinary."
6. Look for unique ID 30146 and click on the hyperlinked text (as of today, this is on the last page of the results, so you will need to click through the documents to go all the way to the end).

" . . . veterinary malpractice . . . is without question the source of most harm to companion animals"

" . . . veterinary malpractice . . . is without question the source of most harm to companion animals"

This quote comes from the fascinating document, "Harming Companion Animals: Liability and Damages," written by Henry Mark Holzer, a professor at Brookly Law School.

This document, among other things, provides information on some landmark case law in the area of veterinary malpractice, including an account of the successful veterinary malpractice case brought by plaintiff "Kenny" against veterinarians F. Richard Lesser, Mark T. Meddleton, and Earl M. Gaughan. In this veterinary malpractice case Kenny was awarded $100,000 in New York State for the loss of his horse, a three-year old thoroughbred race horse.

This judgement was upheld on appeal in the year 2000.

The abridged account of the case cited in the "Harming Companion Animals" document includes the following information:

" . . . [the] plaintiff's three-year-old thoroughbred race horse underwent arthroscopic surgery for removal of a chip fracture in his right front fetlock [performed by defendant] . . . the horse was anesthetized with a combination of drugs, the bone chip was successfully removed and the horse was transported to a recovery stall. While in recovery, the horse went into cardiac arrest and died."

The horse's owner, Kenny, said that his horse had been over-anesthetized and had not been properly monitored during surgery, and that the horses death was therefore caused by the actions of the veterinarians.

"There was no dispute at trial that plaintiff's horse succumbed to the effects of the anesthesia administered during surgery. The debate was over whether this horse was among the small percentage of equine patients that simply do not survive anesthesia through no fault of the surgeon and/or anesthesiologist . . .or whether an act or omission on the part of [the veterinarians Lesser, Meddleton, and Gaughan] caused his death . . ."

Kenny, the horse's owner, had an expert testify. The expert was Nicholas Dodman, a board certified veterinary anesthetist who is a professor at Tufts University School of Veterinary Medicine.

Dodman testified that "the care and treatment rendered by [the anesthetist and surgeon] included departures from accepted standards of veteirnary practice which caused the horse's death.

Dodman said that "the dosage of one particular drug administered to the horse . . . over a short period of time, particularly in conjunction with the admnistration of a large dosage of another drug . . . and an inordinately high level of a gaseous volatile anesthetic . . . constituted a departure from accepted standards of veterinary care. These dosages, according to Dodman, caused the horse to become respiratorily and cardiovascularly depressed, a condition which went undetected . . . When disconnected from pure oxygen after surgery, Dodman's testimony continued, the horse could not sustain himself on room air only. Dodman also opined that the monitoring procedures employed . . . were substandard."

Specifically Dodman said that when the anesthetic Halothane (known to depress cardiovascular and respiratory systems) is being administered, standard practice requires that a patient be monitored by the use of an aneroid gauge to measure blood pressure, blood gas monitoring equipment and/or an electrocardiogram monitor. This was not done by the vets who did surgery on Kenny's horse, who said that they merely observed the horse visually and took a peripheral pulse. (Note: The owner, who was in the room at the time, said that the veterinarian NEVER took the horses pulse.]

Dodman also noted that one of the veterinarians had failed to record notes in the patient record that might have enabled him to document and see the developing trend of respiratory and cardic depression in the horse. "Dodman opined that [when] . . . an orthopaedic patient is anesthetized with gaseous Halothane, it is a departure from standard practice not to keep such notes."

It was also established at trield that after Kenny's horse died, the veterinarian created a chart of the entire procedure retroactively. The document says that this post-operative record attempts to document, in time and dosage the various drugs administered during surgery, as well as the horse's vital signs at intervals. THIS RECORD WAS NOT CREATED during the surgery itself. The jury further learned that after creating this chart, the veterinarian made additional changes to it.

[Lies and the lying liars who tell them, huh?]

In Holzer's analysis, the Kenny v. Lesser case demonstrates: conduct below the acceptable standard of care because of the way the anesthesia was handled and monitored; foreseeable injury or death if it was not handled and monitored correctly; and not having done so being the proximate cause of the horse's death.

As mentioned above, the jury awarded Kenny $100,000 for the loss of his horse.

Links:

Information on the Kenny v. Lesser appeal

Information on the Document, "Harming Companion Animals: Liability and Damages," by Henry Mark Holzer. I really recommend you order a copy from the Institute for Animal Rights Law.

Here is a link to a veterinary technician manual which says that animals on halothane require close monitoring.


Summary of an article from the journal "Veterinary Anaesthesia and Analgesia" on the cardiovascular and respiratory depressant effects of halothane used in horses

Abstract of a Journal of Veterinary Internal Medicine Article on Malignant Hyperthermia, a Problem Seen with the Use of Halothane in Horses