A (vaccine) shot in the dark

Dr. Hart has been practicing veterinary medicine for 31 years. He's done a little emergency work, a ton of relief work, and many shifts in many municipal vaccination clinics.

When he did all that short-term work, he always brought along his long-time veterinary technician, who knew his style and needs. She came as part of his service package for no additional fee. This was in keeping with his philosophy of shaping his practice of veterinary medicine to meet his needs.

On a Saturday morning in April, Dr. Hart had scheduled three municipal rabies clinics, each three hours apart. The clinics ran two hours, and he allowed an hour for rest and travel between each one. His experienced technician efficiently prepared the vaccinations, handled the paperwork and interfaced with municipal personnel.

On this Saturday morning, Herbie, a 10-year old golden retriever, was preparing to take the half-mile walk with his mistress to a local rabies clinic at the firehouse. As always, Ms. Collins gave Herbie his morning thyroid medicine and daily NSAID tablet.

Eventually, Herbie made it in to see Dr. Hart. Ms. Collins and the doctor exchanged some small talk and a couple of quick questions about relevant medical history. Herbie received his vaccination and then moved out of line. Dr. Hart was almost finished and started packing up his essentials, leaving his technician to attend to cleanup.

After a 10-minute walk, Herbie started to vomit. Ms. Collins returned to the firehouse and spoke with Dr. Hart's technician. The tech promptly called the doctor, who was on his way to the next rabies clinic, and told him that a recently vaccinated dog was now vomiting.

"Sounds like a vaccination reaction," Dr. Hart said. "Give the dog a steroid injection and advise the owner to consult her veterinarian."

Dr. Hart explained the injection specifics to the technician; he always made sure to bring steroids and epinephrine, in case vaccine reactions occurred. The injection was given, and Herbie soon felt better and went home.

Early the next morning, Herbie resumed vomiting. Ms. Collins also saw some blood when he threw up. She took him to her veterinarian, who diagnosed a gastric bleed secondary to his NSAID usage. His recent steroid injection had likely exacerbated the smoldering irritation and led to the crisis. Fortunately, after much diligent care and owner heartache, Herbie recovered.

Ms. Collins contacted Dr. Hart to voice her displeasure. She felt he couldn't possibly have known enough about Herbie to instruct his assistant to give the steroid injection sight unseen.

Dr. Hart responded that he had assumed Herbie was having an allergic reaction and didn't want it to get out of hand. He said Ms. Collins was the one at fault, as she should have advised him beforehand as to whether Herbie had any medical issues that would make a public vaccination clinic a bad idea.

They agreed to disagree, but Dr. Hart's liability insurance carrier did pay for the dog's medical bills. Do you think Dr. Hart used poor judgment or was negligent-or do you think he acted in the dog's best interest based on the information available to him at the time?

Rosenberg's response

Dr. Hart assumed this was an allergic reaction just like the many he'd encountered before. However, it's never a good idea to implement treatment without seeing or touching a patient. He did not have an acceptable patient history nor did he even recall who the animal was before he ordered the injection.

He was negligent and was fortunate that he only faced a liability insurance claim and not a state board sanction. All pets, not just private practice patients, deserve equal due diligence. I try to always remember the phrase "First do no harm."

Dr. Marc Rosenberg is director of the Voorhees Veterinary Center in Voorhees, New Jersey. Although many of his scenarios in "The Dilemma" are based on real-life events, the veterinary practices, doctors and employees described are fictional.