Virginia Vet William Will Shows NO LOVE to Patient Kismet

It is a bit ironic that Virginia Veterinarian William Will works at a clinic called the “love” clinic. Because love is certainly the last thing he displayed to his patient, a frightened (as well he should have been) dog whose life he took, sometime after he yanked him out of a truck by his leash so roughly that the dog’s face hit the ground. Also disturbing is Will’s prior disciplinary history, which goes back to 1989.

In an order dated March 2, 2010, the Virginia Board of Veterinary Medicine found that:

“On March 31, 2009 [veterinarian William Will] . . . provided substandard care for ‘Kismet,’ a canine. “When Kismet was frightened and did not respond to urging that he enter the office, Dr. Will pulled said canine from his owner’s truck by leash resulting in Kismet hitting his face on the pavement.”

[And they term this “substandard care?” OK, the word I would use is “abuse!”]

“Following Kismet’s soiling of his clinic’s floor, Dr. Will shouted obscenities which greatly upset Kismet’s owner.”

“Dr. Will diagnosed “parvo” without performing any laboratory tests and suggested that Kismet be euthanized. Dr. Will acknowledged that he ‘chose not to treat the dog due to its demeanor.’”

DEMEANOR? The dog was (wisely) scared and didn’t want to come into his vet clinic, and then was so scared that it pooped on the floor, so Dr. Will decided to issue the dog a death sentence? And they call that “substandard care?” I call it sadism, and murder.

“Dr. Will failed to include pertinent medical data in the patient record of Kismet regarding his March 31, 2009, visit to his clinic. Dr. Will’s brief entry in the medical record referred only to Kismet’s euthanization.”

OK, so let me get this straight: The dog might not have had parvo, and although the vet led the client to believe that he was recommending the dog be euthanized because of parvo, the real truth – as the vet admitted – is that the vet wanted to kill the dog, and did kill the dog, because of the dog’s “demeanor?” Was he exacting retribution against the dog for being afraid of him, and for pooping on his floor?

The document goes on to say:

“A consent order of the Board, entered March 4, 2009 (“Board’s Order”), ordered that Dr. Will’s clinic uundergo an unannounced inspection within the subsequent six month period. On July 19, 2009 and inspector from the Department of Health Professions inspected Dr. Will’s clinic and found that he was out of compliance in two areas. A) Dr. Will’s surgical suite was unsanitary. B) Syringe’s were left on the counter tops of Dr. Will’s pharmacy and grooming areas.”

In it’s “Conclusions of Law” section ,the board cite’s violations by section of Virginia code only – which seems to be a neat little trick to avoid naming, in layman’s terms, the violations the vet was found to have committed. A member of the public would have to actually go through the trouble of looking up each cited code section to determine what violations were found. So we will do that here.

Unprofessional Conduct (violation of Virginia code 54.1-3807(5)) and VAC 150-20-140(6) and (7)

Recordkeeping Violations (violation of the above cited Virginia code section as well as Veterinary regulation 150-20-195)

Violation of Standards for Veterinary Establishments (violation of the above cited Virginia code section as well as Veterinary regulation 150-20-200 (A) (1))

So get this:

The Veterinary Board suspended his license for 2 years but STAYED all but 30 days of that suspension (and frankly, from the information available online, I wonder if they may have even stayed that 30 days, because the site shows a “stay” of suspension order).

They ordered him to take 15 hours worth of continuing education in customer relations, practice management, and “controlling controlled drugs.”

[Gee whiz – yanking a dog out of a car by its leash so that its face hits the ground, then killing it because you don’t like its demeanor – that’s just a ‘customer relations’ problem . . .????? What, no classes in ‘How not to be a psycho asshole?’]

They fined Will $5,000 and ordered that his clinic be subjected to unannounced inspections.

But wait . . .
Dr. Will already had failed an inspection by the board. In yet another consent order issued by the Veterinary Board, dated March 4, 2009, the Board found that:

“On November 4, 2008, an inspector from the Department of Health Professions performed an inspection of the Love Shop Veterinary Clinic, Halifax, Virginia, where Dr. Will is employed as veterinarian-in-charge. The following deficiencies were discovered in the course of said inspection:

a. The facility, including the surgery room, was not clean nor was it sanitary.

b. The facility lacked an animal identification system that would identify all animals kept on the premises.

c. There was no resuscitation bag on the premises.

d. There were no signed disclosure forms in the patient files.

e. Medications in pill and syringe form were unsecured, with open pill bottles in the pharmacy area and syringes left on counter tops in the surgery area and elsewhere.

They fined him $500 and reprimanded him, ordering that his practice also be subjected to an unannounced inspection within 6 months of the date of the order (March 4, 2009).

Why are they yet again including unannounced inspections as an action against this vet when already, he has failed to clean up his act after inspections have found his premises, including his surgical area which should be sterile, filthy, in addition to other violations? More importantly, notwithstanding their $5,000 fine (hefty by Vet Board standards) WHY ARE THEY ALLOWING THIS VET, WITH A LONG DISCIPLINARY HISTORY, TO PRACTICE AT ALL?

As stated above, Will’s first violation, according to Board records from 1989, occurred in 1987. It was over two years between the incident itself and the Board’s order. In that case, the board found that:

“ . . . Dr. Will treated Flash, a canine owned by Ms. Sherrie Talley, in a substandard manner by not performing an adequate preoperative evaluation in that he did not take a preoperative radiograph. That Dr. Will did not refer the patient to a specialist, but instead attempted treatment that he was not properly qualified to perform.” Then the Board document states “That as a result of the aforesaid substandard treatment, the fractures did not heal properly, and euthanasia of the canine occurred on or about June 16, 1987.”

In that case, the board merely fined Will $100.

The question that must be asked in cases such as this is:

Do State Veterinary Boards bear some responsibility for ongoing acts of negligence, substandard care, unprofessional behavior (including physical violence) of veterinarians when those veterinarians show a pattern going back years, with multiple violations, and yet the Vet Boards give the vets a mere slap on the wrist time after time – IF THAT?

Do the overseers of a regulated industry (in this case, veterinary medicine) become RESPONSIBLE for ongoing violations and the impact of those violations (up to and including death) when they clearly practice lax enforcement and issue laughably miniscule or clearly ineffective penalties time and time again, all the while allowing repeat violators to keep practicing their “business as usual?”

Certainly, this question has been asked repeatedly about the Minerals Management Service in the wake of the Gulf Oil “spill” (more like a volcano) – and I can’t help but think of our nation’s veterinary boards whenever the incident in the Gulf prompts discussion about regulators who fail to regulate, because they are “in bed with” the people they are supposed to enforce standards for and regulate. I do believe that those organizations become criminally responsible for the havoc that is caused by the repeat-offender professionals they refuse to adequately regulate.

A History of Prior Violations and New Allegations of Animal Cruelty, but The CA Vet Board Still Wants Them to Get Their Filthy Paws on your Pets!!!!

The Order Signed by the California Veterinary Board in August, 2008 wasn't the first violation committed by Oasis Veterinary Clinic and Hospital and Ronald Walker, DVM, its managing vet. In 2006 the CA Vet Board ordered Walker and his clinic to "take such measures as [were] necessary to practice at an acceptable level of care." Yet, the dizzying and frightening list of violations alleged by the CA Vet Board -- seven in all, including an animal cruelty -- beg the question: WHY DOES THE CALIFORNIA VET BOARD ALLOW OASIS AND WALKER TO CONTINUE PRACTISING

AT ALL?

The facts are these:

Approximately 3 years after fining and disciplining Walker, the Veterinary Board issued an accusation against Walker and his clinic based on an inspection conducted by a board investigator. The Vet Board charged Walker and his clinic with:

• Unsanitary Conditions


• Failure to Maintain Aseptic Surgical Suite


• Animal Cruelty


• Failure to Comply with Emergency Services Requirements and Inoperable Phone


• Maintenance of Misbranded or Expired Drugs


• Violation of Health & Safety Code Section 2514.13 (this deals with failure to properly dispose of x-ray developer fluid, which the inspector said was being improperly disposed of into the public sewer. Public health endangerment, perhaps?


• Failure to Provide Medical Records on Demand

The outcome of this case is that the Board entered into (yet another) "stipulated settlement" with Walker and Oasis. In this settlement, Walker and his clinic admitted to all of the charges except for animal cruelty - and guess what? As part of the "settlement" with the vet, the Vet Board simply dropped (dismissed) it's animal cruelty charges. Please read what the investigator report says, you be the judge! (It is right for the vet board to dismiss charges of animal cruelty in spite of what the investigator saw with his own eyes!???)

For the remaning 6 violations, the vet board placed them on 3 years probation. They ordered Walker and the hospital to reimburse them for their "enforcement" costs, in the amount of $3,575. Please note that this was reimbursement to the board for it's costs, NOT a punitive fine for their dizzying and horrifying violations. Outrageous! No punitive fines! The Board ordered them to take 8 hours a year of continuing education -- that's just one working day!

Oh, the Board "revoked" their license but STAYED THE REVOCATION (which means, pretty much, decided not to enforce it), opting instead for mere probation which means of course, they keep funneling pets in the door.

Now, you tell me: Given the history of prior violations, and the truly frightening findings of the Board investigator (details below), do YOU think the Board's discipline is sufficient, either as a punitive measure or to incentivize Walker and Oasis to clean up their act? More importantly, is it sufficient to "protect consumers and animals" -- which they SAY is their mission?????

Here are the accusations based on the investigation, in detail. You will recall, as I stated above, that Walker and Oasis admitted them all except for the animal cruelty charge -- so the vet board simply retracted that charge in the final settlement. I guess BOTH Walker AND the Board know what kind of incendiary effect an admission of animal cruelty might have on public perception of a vet -- but unless the investigator is outright lying (do you think he is, with everything else Walker admitted to?) then he SAW what he SAW, so YOU be the judge as to whether it is "cruelty" or not -- I certainly think it is!

As you will read, among the allegations ADMITTED to, include caged animals sitting in their own waste with no food or water, keeping used syringes to be cleaned for RE-USE (!), un-sterile conditions including dirty surgical instruments, and more!

UNSANITARY CONDITIONS
(The truth of this charge was admitted by respondents Ronald Walker and Oasis Veterinary Clinic in the settlement)

"On or about January 25, 2008, during the course of an unannounced inspection, the Board's inspector identified many violations of the Board's standards of cleanliness and sanitary conditions, including, but not limited to, the following:

• a. The reception area was dimly lit, and smelled of urine


• b. Bulk liquids were stored in a cupboard with a mixture of spilled medication completely covering the cupboard's bottom, cementing an old cardboard box and stuffed animal toy along with the bottles to the bottom of the cupboard.


• c. The treatment area was dirty and had a pit bull patient with wounds on its rear legs running around freely. This dog had no access to food or water.


• d. The treatment room's counter was dirty and had 15-20 used syringes with needles stabbed into a pad, many used needles in the sink, a plastic jar full of used needles, and several used needles lying around the sink. There were also used syringes with condensation inside apparently to be used on patients again. The floor was dirty with blood and scrub, or surgical soap. Many old endotracheal tubes, some without viable cuffs, were piled in a bowl on a dirty cart.


• e.The surgery room's sink was dirty and appeared to be partially disconnected from the water supply, but still connected to the drain. The surgery table was littered with used surgery instruments, including several hemostats still clamped to a uterus. The mayo stand (a small stand used in surgery) was covered in blood and dirty instruments. A surgery pack was opened and used for a procedure, but there was no indication of a sterile indicator in the pack remnants. The flooring was cracked and pulling away from the wall in places. The wall was damaged and has chunks missing in one corner.


• f. The ambu-bag, a squeezable bag used to assist a patient to breathe, was left out on the O2 tank rack and was crushed and covered in an unidentifiable sticky black material. The stored packs, packs of surgical instruments used for a procedure, were wrapped in porous towels and had no sterile indicator tape on them. The orthopedic kit was not sterilized. The door from treatment into surgery has a hole in it were the window used to be.


• g. The back kennel area was extremely dirty and smelled so strongly of animal waste it was difficult to breathe. Every animal there was sitting in a mixture of feces and urine. None of the dogs had food or water. Only a cage with two kittens had food and their water was dirty.


• h. The bathing area had water flooding on the floor. There was also a bucket of used needles and syringes which were apparently waiting to be cleaned for re-use."

FAILURE TO MAINTAIN ASEPTIC SURGICAL SUITE
(The truth of this charge was admitted by respondents Ronald Walker and Oasis Veterinary Clinic in the settlement)

During the inspection referenced above, the inspector found that:

"The surgery room was not clean and sterile. The floor and walls have damage that makes it impossible to adequately sanitize certain areas as required . . . The instruments that were present were dirty, including the presence of animal tissue in violation of [citation]. The surgical packs present were wrapped in a porous material that would allow contamination to strike through the material and contaminate the instruments inside. There were no devices to measure and confirm sterility of the packs pursuant to the requirement of [citation]. A sick patient was being housed in the aseptic surgery room. This patient might have contaminated the room, exposing the next patient to risk of illness. The sink in the surgery room with the connected drain is a source of infection for patients. The condition of the surgery room was so inadequate that no surgeries could be properly performed there, and, in any case, [Walker] did not have the necessary equipment to perform sterile surgery."

ANIMAL CRUELTY
(Walker and Oasis Veterinary Clinic denied these charges, and the vet board withdrew them. However, in the "accusation", the inspector for the board reported seeing the following . . . )

• a. There were two dogs (patients) running free, one in the treatment room and one in surgery. Neither dog had access to food or water. The dog in the surgery room appeared to be very ill, barely responding when the inspector entered the room. The dog also appeared to have an injury on its left rear leg. All of the client-owned animals in the treatment room cages had feces and uring in their cages. Two cats had no litter boxes, food or water in their cages. One of the cats appeared very ill and the Board's inspector was told that [Ronald Walker and Oasis Veterinary Clinic] were not treating him because the owners were probably going to euthanize him. Otherwise, the Respondents' employee did not know who the patients were, and was unable to indentify them by name or owner.


• b. The kennel area was extremely dirty and smelled so strongly of animal waste it was difficult for the inspector to breathe. The runs did not have passive drainage, and all the animals were sitting in feces and urine pooled on the floor of the compartments. None of the dogs had food or water. All bowls were empty. Two kittens had food in their cage, and only dirty water."
  

EDITORIAL COMMENT: I find it outrageous, and a perversion of justice, that the veterinary board withdrew the animal cruelty charge -- which was based on its own inspectors report -- particularly when many of the same allegations in the animal cruelty charge were repeated in charges that the vet, Ronald Walker, ADMITTED TO. He admitted to the truth of the other six counts. Those six counts include a reiteration of the observation that animals were kept in their own feces, most without access to food and water. Is this, or is it not, cruelty? Don't ask the vet board -- apparently, just a little resistance from the vet, and they change their mind and decide that it's not. DO YOU THINK IT'S CRUEL?

FAILURE TO COMPLY WITH EMERGENCY SERVICES REQUIREMENTS AND INOPERABLE PHONE
(The truth of this charge was admitted by respondents Ronald Walker and Oasis Veterinary Clinic in the settlement)

During the inspection described above, the inspector found that Oasis Veterinary Clinic "did not have notices posted outside their building of where emergency services could be obtained when their clinic was closed as required . . . The phone number listed for emergencies was the clinic's own telephone number . . . [which they admitted] had been inoperative for some time, and the number was not answered when the Board's inspector tried to call it. Moreover, there was no functioning answering machine to provide an outgoing message as to where emergency services could be obtained. Additionally, there was an absence of notice that there was no 24-hour supervision of patients as mandated . . . Finally, the facility was found closed during nomral posted business hours, yet no referral was available for emergency services."

MAINTENANCE OF MISBRANDED OR EXPIRED DRUGS
(The truth of this charge was admitted by respondents Ronald Walker and Oasis Veterinary Clinic in the settlement)

The inspector found that "The pharmacy area was stocked with many expired drugs, which Respondents' employee indicated were routinely dispensed to the animals treated at [Oasis Veterinary Clinic & Hospital]. The controlled drug drawer was unlocked . . . The vaccine refrigerator/freezer had human food stored in it. The bulk liquids were stored in a cupboard with a mixture of spilled medication completely covering the bottom, cementing an old cardboard box and stuffed animal toy along with the bottles to the bottom of the cupboard. There were several bottles of liquid medication pre-packaged with only a drug name on them. These bulk and expired drugs which were either expired or so oldthat the expiration dates of the drugs could not be read, and the stuffed animal which was adhered to the medication spilled in the cupboard . . . The sale of expired prescription drugs is prohibited by law."

VIOLATION OF HEALTH AND SAFETY CODE
(The truth of this charge was admitted by respondents Ronald Walker and Oasis Veterinary Clinic in the settlement)

The inspector found that Oasis Veterinary Clinic's "x-ray developer is a hand-dipping tank, and was set up to have the chemicals drain into a pipe connected to the public sewer system. The x-ray waste generated . . . contains a silver-conten levfel that exceeds that which may properly be disposed of into the public sewer, and [Oasis Veterinary Clinic did not] have a contract with a licensed company for the disposal of their x-ray waste, or otherwise provide for the proper disposal of Respondent's x-ray waste in accordance with applicable law."

[ Oh, great! Threats to human health, as well!]

FAILURE TO PROVIDE MEDICAL RECORDS ON DEMAND (The truth of this charge was admitted by respondents Ronald Walker and Oasis Veterinary Clinic in the settlement)

" . . . The Board initiated an investigation based on a consumer complaint submitted by a consumer, Ms. J. J. on July 10, 2007. The complaint stated that on June 20, 2007, Ms. J.J. took her 5-year old Miniature Pinscher, Rex, to [Oasis Veterinary Clinic] for a neutering procedure and [he] ended up dead. As part of its investigation, the Board requested that [Oasis] produce the medical records for Rex. [Oasis Veterinary Clinic] failed to do so and later reported that the records for Rex were 'shredded' and destroyed . . ." [An Oasis employee later] "informed the Board's inspector that notwithstanding Respondent's requirements to maintain animal records fore a minimum of three years, [Oasis Veterinary Clinic] had a practice of destroying old records, including records of animals that died, such as Rex."

South Carolina Vet Robert Moorhead: " . . . engaged in incompetent or negligent conduct"; does surgery on dog's leg without taking x-rays first

I find it interesting that "bad vets" tend to maintain licenses in multiple states. Usually, these states are contiguous or near each other. But Robert M. Moorhead, DVM, had licenses in Colorado and South Carolina in recent years.

I also find it interesting how many "bad vets" either are involved, or get involved, in the horse business, after a history of violations on smaller companion animals.

In early Fall 2001, a pet owner brought his dog to Moorhead's clinic, after the dog had been struck by a car.

Moorhead did not have an x-ray machine at his clinic. But that didn't stop Moorhead from diagnosing the dog's injuries and proceeding with surgery, which he did the next day. According to the board document, Moorhead "performed an open reduction in which he inserted a pin into the femur and wrapped the break with wire mesh inside the leg."

Subsequently, the pin Moorhead had placed in the dog's leg started to come out. Moorhead then "removed the pin" (?? did that involve another surgery??) and "placed the dog's leg in a soft cast." The following month, the dog started to develop an open sore. The owner took his dog back to Moorhead, and Moorhead did ANOTHER surgery. According to the Board document, this time Moorhead:

"removed bone chips from the leg and inserted two pins from the stifle joint and into the femur."

Two months later (December), Moorhead examined the dog and sent him for x-rays at another clinic. The document does not say what these x-rays showed. It does not say what Moorhead saw on them, or if he even ever reviewed them.

Subsequently, on Christmas Eve, the owner ended up taking his dog to the University of Pennsylvania Veterinary Emergency clinic. On January 4, the dog's leg had to be amputated,

"because the leg had never healed, the hip joint had been broken, and the knee joint had been destroyed by the pinning procedure."

So, I'm sure that many of the same questions that come to my mind are in yours right now, such as:

"Was the dog's hip broken from the original accident, and Moorhead missed it and failed to do anything about it? If so, is this because he had no x-ray equipment and decided he could simply diagnose all the dog's injuries on exam alone? Or, did the dog's hip subsequently break because of stress from walking with a broken, improperly or inadequately pinned leg?"

"Was incompetent treatment on the part of Moorhead responsible for, or a contributing factor to, the dog ultimately having to have his leg amputated? Had he received more competent treatment, would he have been able to keep his leg??

The South Carolina Board found that Moorhead had failed to keep adequate records when he saw the dog in September and October. They go into some detail about the recordkeeping violations in their decision, including Moorhead's failure to document the type and amount of anesthesia given the dog.

Interestingly, they slip another citation into the document, referencing only the code violated. But unlike the recordkeeping violation, the South Carolina Vet Board doesn't bother to tell the reader what that section of code pertains to. Of this violation, the document says only:

"The Respondent has violated S.C. Code Ann. 40-69-140(1) (2001) in that the Respondent violated regulations of the Board, specifically, Regulation 120-6.1."

Hmm, what in the heck is 120-6.1?

Why do they gloss over that, without quoting what that violation is about, whereas -- by contrast -- they go into detail about the meaning of the recordkeeping violations?

This is supposed to be a public record. Yet, I believe, the way the Board has drafted this (and other) findings of fact, is a deliberate attempt to protect the offending vet, and a deliberate attempt to "hide in plain sight" the worst violations. To hide this from the public, specifically the pet owning public. To keep them from having this information as the basis of making decisions about Moorhead as a vet.

They know that most readers won't spend the time it takes (which can be SIGNIFICANT) to search through the South Carolina Code, find this section, and reference it so that they can interpret what it means.

But, this sneaky little citation is the most important one. And thanks to the Colorado Veterinary Board -- where Moorhead was also licensed -- we know what this violation means.

In 2004, the Colorado Vet Board disciplined Moorhead as a result of his South Carolina violation. Their order states:

"The South Carolina Board also found that the respondent . . . engaged in incompetent or negligent conduct in the practice of veterinary medicine by failing to take preliminary radiographs to determine the best method of fracture repair in order to facilitate a complete return of function of the patient's leg."

Well, thanks, Colorado Vet Board: If it weren't for you, we might never have known the SC Board found him incompetent or negligent.

Just goes to prove that public records aren't always all that accessible to the public in all senses of the word.

However, we can't thank either the South Carolina Board OR the Colorado Board for taking anything like serious action in this case.

The South Carolina Vet Board suspended Moorhead's license to practice, but IMMEDIATELY stayed the suspension. "Stayed" means that not even one day of the suspension was enforced.

They put Moorhead on probation for 2 years with terms that include providing "quarterly reports of four cases" (presumably of his own choosing) to the Board, including one surgical case and four medical cases.

They also required him to retroactively RE-CREATE records for this case.

In other words, after finding him to have been negligent or incompetent, they are disciplining him by ordering him to do another surgery and submitting information about that.

They did, at least, order him to get an x-ray machine before doing this (or any other) surgery and to take 10 hours of continuing education in orthopedics and anesthesia, respectively.

And after finding him in violation of recordkeeping in this case, they are not merely inviting him, but ordering him, to retroactively create records for this patient nearly 2 years after-the-fact.

Gee, wonder how factual truthful, and accurate those records will be????

They fined him $500 and the costs of the investigation.

Colorado also suspended his license and immediately stayed the suspension, enforcing not one day of it.

They put him on probation for a little over a year or until the South Carolina order's provisions were met.

Oh, about that horse thing:

A websearch of Robert M. Moorhead finds this:

Robert Moorhead listed at Carolina Sport horses

Gee sport horses? I bet they have their share of orthopedic injuries. I'd be concerned about their care.

Links:

South Carolina Board Order

Other:

Colorado Orders:

2 Counts of Substandard Care and 5 Recordkeeping Violations for Maryland Vet Richard Springer

This entry is about Richard Springer, of Brandywine Animal Hospital in Clinton, Maryland.

In early 2005, an owner brought "her dog 'Baby,' a four-year old male Yorkshire Terrier, to Dr. Springer for veterinary care, believing that her dog was constipated. According to the Veterinary Board's charging documents, in her complaint against Dr. Springer, [the owner] noted that Baby had been 'acting strangely' and yelped whenever he was picked up. In his written response [to the complaint] Dr. Springer noted that Baby was presented for 'pain.'

"In his written response to [the complaint], Dr. Springer also noted the following: (a) Baby had never been to his office and had no history of being seen by a veterinarian in two years; (b) On physical examination of Baby, the noted 'a large fecal mass in [dog's] posterior colon"; (c) On visual examination of the dog's oral cavity, he noted a 'moderate tartar accumulation on most teeth, gingivitis, and probable periodontal disease'; (d) He could not obtain an accurate body temperature for the dog rectally; (e) Because of the dog's medical history, he made a differential diagnosis of canine disk diease, and decided to take an abdominal radiograph;" . . .

OK, pay attention to the next part . . .

"(f)Baby 'defecated and urinated freely and became temperamental when placed in a right lateral [recumbant position]; (g) Baby 'bit freely into the X-ray gloves'; (h) He noted that the radiograph was 'negative for obvious disk disease,' but showed a large air density in the [dog's] posterior colon;' and (i) He made '[a] diagnosis of colonic obstruction due to fecal impaction," and injected cortisone for inflammation, and then discharged the dog."

The Board goes on to say that the information Dr. Springer provided in response to the complaint did NOT appare in the patient record. They say that Springer did not record Baby's medical history and condition, did not record his diagnosis, did not record his treatment or the medications given to Baby, and did not record the "progress and disposition" of the case.

They further noted that Springer failed to meet standards for taking x-rays. Specifically they said that "For diagnostic purposes, a minimum of two radiographic views is highly recommended. For radiation safety purposes, the radiography should be limited to the specific area of interest. Neither standard was met . . . "

The Board adds -- pay attention here, and ask yourself what the implications are . . .

"Dr. Springer noted that Baby was an excited, fractious patient. In such cases, tranqualization or sedation of the animal may be necessary, unless contraindicated, to secure the radiographs, patient comfort, and handler safety."

So -- since he did get x-rays -- how then, did he get this fractious patient to lie in the right position and hold sufficiently still without any sedative? And what might his method of achieving this have to do with Baby's fractured jaw - if anything at all?

The Board continues:

"Having diagnosed that Baby was suffering from colonic obstruction due to fecal impaction, Dr. Springer's workup should have included a more focused examination to rule out colonic, rectal, or prostatic pathology. In the absense of an underlying disease, treatment should have included digital evacuation of the rectum-colun an/or administration of mild enemas. Dr. Springer has not provided any information indicating that he performed any of these procedures. Dr. Springer administered cortisone to treat inflammation, but such drug may have been contraindicated under these circumstances."

The Board also notes that Springer made no plan to treat the periodontal disease he identified.

The document goes on to say:

"When [the owner] went to the hospital's kennel area to help retrieve Baby from his cage, she noted that her dog's mouth was bleeding and in an open position. [The owner] asked Dr. Springer about this, and he told her that Baby was "Okay," that the dog had just cracked a tooth. If Dr. Springer examined Baby's mouth, he failed to note the severity of the injury the dog had sustained."

"After arriving home, Baby would not eat or drink . . . [the owner] also noted that that dog was unable to close his mouth. [The owner] called Dr. Springer and informed him of this problem, and asked that he examine her dog. Dr. Springer directed [the owner] to take Baby to Southern Maryland Referral Center located in Waldorf, Maryland."

The owner took Baby to another hospital, where the vet told her that Baby had a fractured jaw. He was sent to an emergency clinic where a "mandibular fracture" (broken jaw) was repaired.

Most of this detail does not appear in the "Consent Agreement," however.

The Board fined Springer $1,850. They suspended his license for 2 weeks, BUT STAYED THE SUSPENSION, which means that NOT ONE DAY of the suspension was enforced.

They placed him on probation for 6 months, but that probation is pretty meaningless, since the only term of the probation is to obey the regulations he already should have been obeying in the first place.

So -

How did Baby's jaw get broken?

And why did Springer tell Baby's owner that Baby was "Okay" and only had a cracked tooth when she arrived at the vet hospital to see her dog Baby bleeding from his mouth which was apparently hanging open?

Did Springer really not KNOW that Baby's jaw was fractured? (How unobservant, or ignorant, would he have to be not to know that?)

Or did he know it but just not say?

If the latter, why? Does it have anything to do with uh, Baby's "fractious" ness?

The Colorado Vet Board Sucks: Tells Konishi -- Yeh, Go Ahead and Retroactively Create Medical Records!

In human medicine, it is estimated that only a very small percentage of those individuals harmed by medical errors or malpractice ever file a complaint or sue.

I feel certain that the same is true in the veterinary realm.

As a rule, something pretty bad has to happen for a pet owner to go through the time and trouble to file a complaint with a vet board -- a process which holds no promise of recompense, but is done to call attention to what the complainant believes to be practices that are dangerous for pets.

So, as I read the Colorado Veterinary Board's "Stipulated Letter of Admonition" admonishing veterinarian Benjamin Konishi, the question that I ask is: "What happened to the horse to compel the owners to file a complaint????"

The answer may be in the board's comments, brief and cryptic as they are:

" . . . the Board found that you failed to properly keep records. The board also found that you treated a horse whom was laterally incumbent [sic], which increased the animal's vulnerability to aspiration and pneumonia as a consequence of the treatment."

Did the horse get aspiration pneumonia as a consequence of the vet treating this horse while he was "laterally incumbent" (I'm quite certain this should have been RECUMBENT. No, the vet board doesn't seem to have a great command of english . . . .)

This seems to me to be implied.

The Colorado Vet Board found that Konishi had violated two statutes of the Veterinary Practice Act. They cited the numbers of those statutes in the "Letter of Admonishment" -- "C.R.S. 12-64-111(1)(a)" and "C.R.S. 12-64-120(3)(b)". Of course, no consumer would know what those numbers meant -- and in this document, the board doesn't bother to tell them. You would have to cross-reference this document with the actual statues to know what violations they found Konishi committed. This is one of the reasons the Colorado Vet Board sucks -- this document is very unfriendly to the viewing public, not forthcoming with information.

Here is what those violations mean --

The first violation -- the violation of 12-64-111(1)(a), means that Konishi committed:

"An act or omission which fails to meet generally accepted standards of veterinary practice.”

The second violation -- the violation of 12-64-120(3)(b), means that Konishi violated the provision that states:

“All practicing veterinarians . . . shall maintain accurate records for every new or existing client-patient relationship . . . Animal patient records shall justify the assessment, diagnosis, and treatment administered or prescribed and shall be legible, written, printed, or prepared electronically as unalterable documents. Records shall be prepared in such a manner that any subsequent evaluation of the same animal patient would yield comprehensive medical, patient, and veterinarian identifying information. Records shall be maintained for a minimum of three years after the animal patient’s last medical examination.”

Here is another reason why the Colorado Vet Board sucks:

In spite of finding Konishi in violation of these statutes, and implying that his actions put the horse at risk for pneumonia, the board had only two requirements for Konishi:

The second was that he complete 6 hours of continuing education in acute abdomen diagnosis. (Hmmm, does that mean he also misdiagnosed this animal???)

The first was very outrageous. The vet board ordered Konishi to "Write records in connection with this case within 12 months."

EXCUSE ME???????? You are finding him in violation of record keeping rules and then you tell him to RETROACTIVELY CREATE RECORDS for the case that spurred the complaint and you give him a YEAR TO RETROACTIVELY CREATE RECORDS?

EXCUSE me, he was supposed to have records that are UNALTERABLE . . .already.

The statute says that the record must "justify the assessment, diagnosis, and treatment administered or prescribed . . . " yet they state that he administered the treatment while the horse was "incumbent" which increased his risk of pneumonia -- so either he lies in the records he creates and makes it look like he didn't do those things, OR he violates this statute all over again by failing to meet its "justification." Also, the board ordered him to take a class in diagnostics. Did he misdiagnose this patient? If he did, and you are asking him to RETROACTIVELY CREATE A RECORD UP TO A YEAR LATER, does he RECORD his misdiagnosis??? (If he does, then he violates the statute because he won't be able to justify the diagnosis . . .). But if he doesn't, THEN HE'S CREATING INNACURATE RECORDS!

This is all they did. No fine.

And an incomprehensible order to retroactively create non-existent patient records that either do, or do not, accurately describe what actually occurred.

Pfft.

With friends like the Colorado Vet Board, Colorado's pets sure don't need any enemies.

Disciplinary Action vs. Benjamin Konishi:





Links

Colorado Regulatory Decisions:

Board Orders

Colorado Veterinary Practice Act

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