THE DIFFERENCE
I lost a patient this past weekend. I don’t know why and I will likely never know, as the owners of the dog decided not to have a necropsy to find out. They blame me, however. This would not be the first time I’ve been blamed for the death of an animal (nor will it be the last), and though I can’t be certain, there are likely some that I was responsible for, directly or indirectly----unintentionally, of course. I recall during my senior year of vet school telling a classmate that I was terrified of losing a patient or accidentally killing a pet. A nearby faculty member, typing quietly on her computer, overheard me, and without moving or turning her head, said gently, in a conversational tone, “You will.”
This large-breed dog was spayed at great a low-cost clinic, and though she was a big, obese girl who had recently had puppies, there were no complications with her procedure and she recovered well and went home bright and alert. The next night, the owners called to say that she hadn’t been feeling well the morning following surgery (sadly, they did not call or take her to the vet), and that she had died later that night. Then they emailed--- to say that I was negligent. That I was responsible. That I didn’t know how to properly care for their dog before, during and after surgery. They stated that it was my fault. They even sent an article and asked me to read it so that I understood how to be a good veterinarian and surgeon to other dogs, "so this never happens again."
As people often do, they look to seek blame---they are sad, confused, angry, and need a direction for their feelings. And I understand that. Of course I feel terrible….for them, for the dog. Anytime an animal dies, I am heartbroken, as we all should be if we have any degree of empathy for people and the pets they love. But I do not feel responsible for their dog’s death. I am a good veterinarian and I am a good surgeon. I did everything the way I have typically done in my previous thousands of other surgeries (as did our staff)…..and I care.
I don’t know why this dog died----unknown or unintentional surgical complications, underlying metabolic disease, bleeding disorder, improper home care, etc.---but I do know that the owners had bred this dog, have had several of their dogs spayed at our clinic before without issue, they declined bloodwork, they didn’t reveal pertinent medical history before surgery, and they didn’t call or seek medical attention when they knew something wasn’t right. Though we will never know the significance of these choices or whether the outcome would have been different, partial responsibility, at least, must be placed back on the owners for some of their decisions. I don’t fault these parents for their misdirected anger and hurt, but I think situations like this warrant a conversation about the risks of surgery and anesthesia----specifically the risk differences in surgery in a shelter or low-cost spay/neuter clinic and in a full-service veterinary hospital.
I don’t want to imply that low-cost facilities provide sub-standard care (though people often assume this)---perhaps there are some, but typically this is not the case. In fact, spay/neuter clinics often have very experienced veterinarians who work quickly in surgery, often lowering many anesthetic risks that might be seen in places where pets are under anesthesia longer. In addition to managing my own non-profit organization for pets of the homeless community, I work in two other places---in a low-cost spay/neuter clinic run by a local shelter, and in a high-end, AAHA accredited, full-service veterinary hospital. I have also worked at other well-established full-service hospitals and I do relief work at several other low-cost spay/neuter clinics because I believe in the cause. I am the same doctor in each and I spay and neuter dogs and cats the same way in all places. How can I be a great, caring surgeon in one place and a terrible, negligent doctor in another? Additionally, there is a common misconception that full-service veterinary hospitals are money-hungry, that they price-gouge and charge too much for the services they provide, including surgery. I’m sure this is true for some places, however, for the most part, this is not the case. What I have come to realize is that people simply do not understand the differences and reasons full-service hospitals charge what they do, versus what low-cost clinics provide, when offering the “same” service or surgery. If I had a dollar for every time I heard someone say, “My God, my vet wants to charge me $400 but I can get my pet spayed down the street for 50 bucks!” then I could retire yesterday.
I am going to shed a little light on these differences here so you and those you know can make an informed decision when considering and scheduling your pet’s surgery and where you would like to do this. Why is the surgery $50 in one place and $400 in another? Think about it. It’s the same procedure, but what might be different so that the cost can be less? In order to offer a surgery for a negligible price, corners have to be cut. So I am going to tell you what those corners are (this is variable from place to place, but generally true). And I'm certain my low-cost clinic veterinary colleagues will be amenable to me offering this information because no one is trying to hide anything and we all want the same thing---to work with informed owners and provide a successful, safe surgery for all of our patients.
1) Low-cost clinics do not typically require or offer bloodwork before surgery. One main reason for this is because most young, healthy animals do not have any underlying metabolic issues. But there are always exceptions. If the clinic provides a bloodwork option, your cost will go up. But if you decline the bloodwork or if the clinic doesn’t offer it, if your pet has an underlying medical issue (liver or kidney disease, bleeding disorder, etc.), the vet and staff will not know and the risk for surgical and post-op complications will go up. Or your pet may die. Bloodwork helps your vet and staff know what risks are present, what anesthetic drugs to use and/or whether your pet can even safely have surgery.
2) Low-cost clinics do not usually place an IV catheter or give intravenous fluids to your pet during surgery. One of the reasons for this is that most high-volume spay/neuter veterinarians are able to perform surgery in a fraction of the time of many others (often less than 5-10 minutes), simply due to experience. But why might an IV catheter and fluids be important? Fluids provide assistance with blood pressure stability and perfusion to organs. If your pet has trouble with blood pressure, decreased perfusion to important organs may cause them to fail, typically not seen for days or weeks after your pet goes home. Most young, healthy animals will not have this problem and typically the surgery is quick, but not always. If your hospital provides this, your cost will go up.
3) Low-cost clinics have limited staffing and cannot provide constant attention to your pet before, during and after surgery. There are often only one or two veterinary technicians or assistants on staff during a typical surgery day, and they are commonly multi-tasking. The most consistent time we see complications or accidental death is right after surgery, in recovery---this is true for any hospital or clinic. If your pet is not directly monitored by a technician at all times, if they have any difficulty in surgery or recovery, it is possible that a minute or two (or more) may go by without this difficulty being noticed. This is not intentional, of course---it has to do with the number of staff available. If a hospital provides constant nursing care and monitoring for your pet, your cost will go up.
4) Low-cost clinics do not routinely monitor CO2 levels, ECG, blood pressure and constant body temperature for your pet during surgery. A pulse-oximeter is usually the only monitoring device present, revealing heart rate and oxygen perfusion in the blood, which are important. But other vital signs can be important too. Hypothermia can make recovery long and difficult, ECG readings help determine any heart abnormalities, abnormal CO2 levels can be deadly, and I’ve already explained what low blood pressure can do. Again, the the most common reason for not monitoring these things is that the surgery is often less than 5-10 minutes, so significant changes are unlikely in young, healthy animals. If your hospital provides these other monitoring devices, the equipment costs money and the trained/certified staff member must be paid to be there, use them and know how to manage any complications….so your cost goes up.
5) Low-cost clinics do not provide a full, comprehensive physical exam and vet consultation for your pet before surgery. Exams are limited due to the number of surgeries that must be performed in a day. You do not have an opportunity to discuss your pet’s health and concerns with a vet before the surgery is performed. There may be an area on your drop-off sheet where you can write your concerns, however you likely never see or meet your veterinarian. If your hospital provides time and an opportunity for a comprehensive exam and discussion with your vet, that’s right, your cost goes up.
6) Low-cost clinics are not the best option for higher-risk pets: large and giant breed dogs, senior pets, brachycephalic breeds (those with flat/smashed faces), obese, in-heat, pregnant and aggressive dogs and cats, those with a history of medical issues, etc. Low-cost clinics are not typically set up to handle emergencies if they arise or hospitalize animals overnight for additional care if necessary. They lack the proper equipment, training, staffing and time to handle anything outside of a normal, healthy patient surgery and recovery. If your hospital is set up for this, your cost will go up.
So, you see where the costs are cut? There are liability waivers to be signed and information is provided to help owners make reasonably informed decisions, however, most places do 30-50 surgeries in a day and shelters and low-cost clinics simply cannot afford the time and staffing to have lengthy discussions with every owner about the differences in what they do and what full-service clinics do. And 99.9% of the time, pets recover well in these facilities and there are no issues, so these discussions do not typically take precedence. That being said, owners should take some responsibility and do their own research----if a surgery is $400 in one place and $50 in another, you must use common sense and ask questions to discern this difference (this information is also true for places that offer dental cleanings for $100 versus your vet who quotes you $800---ask questions because there are definitive differences.) Conversely, just because a surgery cost is higher at your vet, it doesn't mean they offer all these other services---again, you must ask questions. Do you provide bloodwork? Does my pet receive a comprehensive physical exam, a limited exam or any exam at all? What sort of monitoring is done? Will there be a technician with my pet at all times? Do you give IV fluids? What do you do in the event of an emergency---are you prepared to handle an emergency? Understand the services offered so you can make an educated decision. Low-cost spay/neuter clinics can be good options for young, healthy, low-risk pets and for those who cannot afford the cost of a full-service hospital---that's why they exist. And that's why I will always support them and continue to do this rewarding, necessary work and help provide a solution to the pet overpopulation problem. But it’s important to understand what you are getting and what you are NOT getting. There are risks. Of course, there are risks regardless of where you go, as some complications cannot be foreseen regardless of the amount of care given and preparation taken, but the risk is higher when you do not understand the above points.
This article is not to dissuade you from using a low-cost clinic----many places are amazing facilities with wonderful, caring, experienced technicians, assistants and veterinarians, and thousands of pets have surgeries in low-cost clinics across the country every day without incident, including many in the higher-risk category above. This information is only to help you understand the differences in the services provided from place to place and how to make an informed decision when thinking about your pet’s surgery. Things cost money. People cost money. Equipment has to be purchased and maintained. Staff must be trained to use this equipment, run labwork, monitor your pet appropriately and recognize and manage complications. Veterinarians must be paid to perform the surgeries and supervise all surgical, anesthetic and post-operative care. Providing additional services requires more time and resources. So, suddenly, a $400 surgery makes sense when you understand what risks you may be taking for $50, right?
Again, I don’t know why this dog died, and perhaps the outcome would have been the same regardless of where the surgery was done or if the owners had done the bloodwork, revealed her health issues or called when she was sick, but after receiving an angry email from a heartbroken dog-parent whose beloved pet died from unknown complications, accusing me of being a negligent vet and not caring for their pet appropriately, I wonder -----if they understood this information and the risks involved, would they have made different choices or paid the $400?
Carolyn Karrh, DVM
