Just over a week ago, I had the honor of receiving the Association of Shelter Veterinarians 2018 Veterinarian of the Year Award. I’d learned that I would be receiving the award a couple months before, and at the time had been pretty stunned. Me? Seriously?
As you know from this blog, I do research and writing projects, some with other people, and more on my own. Since I work on my own, outside of any institution or organization, I don’t have committees, approval, or funding (except on a few projects I’ve worked on with others, for which I have written grants), I don’t have an institutional mission telling me which research topics are of interest to the university, a big donor, or the board of directors, and which topics may be too uncomfortable, difficult, or controversial. For me and my interests and tendencies (i.e., doesn’t always play well with others; has trouble recognizing the preeminence of authority figures), this has mostly been convenient. It has allowed me to follow my interests of the moment, to ask and then try to answer awkward or thorny questions, and to wander.
But it has also meant that I often don’t know how many people have even noticed what I’ve written, if they have read it, and what they think of it. It also means that I have learned to become my own publicist. Thus, I’m writing this braggy blog post in the same way that I worked on press releases for my last two papers– putting it out there because if I don’t announce my own accomplishments, who will? (OK, probably ASV will later, beyond their post in a closed Facebook group, but I want to show off now!).
The Award
Here is a description of the award– this is its first year, so I’m the first recipient:
2018 ASV Veterinarian of the Year Award
Established in 2018, this award recognizes remarkable members of the Association who have been outstanding in their role as a veterinarian to improve community animal health and wellbeing. The ASV’s intent in conferring this award is to bring attention to excellence in sheltermedicine by recognizing those who serve as exceptional role models of the profession. Veterinarians serving in municipal, private, and/or non-profit shelters and other community animal endeavors are eligible; current ASV Board Members are ineligible. The award designee will receive a plaque, a shelter medicine textbook, and a $250.00 donation to an organization ofhis/her choice.
The award was presented at the ASV annual reception in Tampa on October 11, in conjunction with the ABVP (American Board of Veterinary Practitioners) conference and the ASV annual meeting.
Elizabeth Berliner used an appropriate amount of humor while sharing details of my nomination.
Elizabeth Berliner submitted the nomination and described some of the my work– from pot bellied pigs to Shelter Animals Count to ergonomics and of course spay neuter.
Way too excited to be here. Also, maybe Brenda shouldn’t have given me her extra drink ticket.
I gave a bit of an acceptance speech, the main gist of which was, “The research that I do is all about you– the shelter and spay neuter vet– because I want to support what you do, and who you are, because you are super cool.”
Later in the evening, the ASV presented this year’s Meritorious Achievement Award posthumously to my friend Kelly Farrell, who died last year but had been one of the most forward-thinking spay neuter vets I’ve ever met. Her family came to accept the award and it was sad, touching, sentimental, lovely, and heart-wrenching.
How do I have time for research?
I think sometimes people with “regular” jobs (meaning, 5 days a week working for someone else) assume I must do the same, and that any research or other work that I do is on top of this standard work schedule. That’s not really the case– here’s how my work schedule actually works.
My Spay Neuter Work
I love my spay-neuter work, and also, it keeps me “honest” (meaning, grounded in the reality of daily practice) in my research. But because of the model of spay-neuter that I do, I only actually do surgery about 110 days a year.
When I was starting my clinic in 2006 and being mentored by Leslie Appel of SOS in Ithaca, NY, Leslie recommended that I do MASH spay neuter just 2 days a week. She had started her MASH clinic working 5 days a week, then 4, and it was too much, even for her energetic, extroverted self, with the long work days in addition to the lifting, packing, unpacking, driving, etc. I have found that for me, three days of surgery in a week is do-able, but is also enough. With holidays, vacations, conferences, and odd weeks containing Saturday clinics (Saturdays, of course, count both for the week before and the week after), this works out to my 110-120 annual clinic days.
I’m also inventory, boss, budget-master, and book-keeper/accountant, making it a legitimately full-time job, but as time has gone on, these tasks get easier since the clinic schedule, budget, and mission barely change. What this means is that often, I have time on my hands to think, listen, explore, and learn.
My Research
It never would have occurred to me that I could do research and write scientific journal articles on my own without being part of a university or other institution. But back in 2007, when I was a part of the first Spay Neuter Task Force, I got involved with a project to analyze and publish shelter intake and euthanasia data from New Hampshire and Austin TX (since I already had years of NH data). Julie Levy, the experienced but overcommitted researcher in the group, recognized a potential time-management boon and offered that I could be first author if I wrote the paper. I jumped at the opportunity, and thus with her guidance and that of Jan Scarlett, I learned the ins and outs of writing and revising, peer review and eventual publication. Once I had been through the whole process with one journal, it was suddenly conceivable that I could do it again, and on my own. So when I found a question that kept coming up in the spay neuter community, and when I could figure out a way to find (or at least get closer to, and explore) an answer, I did so.
But Why?
During lunch at the SAWA/ National Council on Pet Population research day in 2016, a university researcher asked me why I did research if I didn’t have to. As we talked it was clear to me that what she resented about her own work was the impositions of the university structure, rules, and systems on her research. Whether it was funding or approvals or imposed timelines, the system made research a hassle rather than fun. By doing research outside of such a system, I’ve avoided a lot of that hassle (also, by doing survey-based research outside of an institution, I’ve been able to avoid needing to find an independent human subjects committee to evaluate and approve my research). So I get to learn deeply about a subject and ask interesting questions. What’s not to like?
But Library Access…
How do I get access to journal articles without being part of a university? At home, I have the same limitations as any other internet user. But like many people, I live just a few towns away from a university. And like many universities, it has a library that allows everyone access. When my list of otherwise inaccessible articles on Google Scholar gets long enough, I head on over to the university library and download to my heart’s content. It’s not as easy as having access at home, but it works, and it’s sometimes fun to have an excuse to spend a few hours hanging out in the fancy university town, drinking soy lattes and eating ciabatta.
Life outside
And of course I have a life outside of veterinary medicine: family, pets, walks in the woods, video games, novels, binge-watching Netflix.
So anyway, thanks to those who chose me for this award, and thanks to all of you who have participated in or read or shared my research. I hope you’ve gotten as much out of it as I have ♥
My other accomplishment on October 11: Achieving level 40 in Pokemon Go. This has required countless hours of antisocial behavior staring at my phone. Just ask my mother or my wife.
Several years ago I went to a continuing education lecture with a “surgery updates” session, and the thing I took away from it was this: that waterless surgical “hand rub” formulations are more effective than traditional wet scrub with chlorhexidine, betadine, or the like at reducing skin microbes on surgeon’s hands.
The speaker said that not only were these products more effective, but that they were also cheaper than wet scrub. This sounded great, so I looked up prices and realized that the price comparison was only true if one was comparing pre-packaged sterile chlorhexidine-impregnated scrub sponges to the waterless products. For those of us who were using chlorhexidine scrub “straight from the bottle” on reusable scrub brushes, the waterless hand rubs were much more expensive.
What are surgical hand rubs?
Surgical hand rubs are generally alcohol-based and may also contain chlorhexidine. These products aren’t the same as over-the-counter alcohol-based gel hand sanitizers or similar products. Some of the companies that make surgical hand rubs also make similarly-named hand sanitizers for non-surgical use—basically, for hospital worker hand sanitation. For example, Sterillium makes a Sterillium Rub Surgical hand scrub as well as a Sterillium Comfort Gel– the first costing $75-$125 per liter, the second costing about $18-$30 per liter. The lower-cost similar products may be tempting to purchase, but they generally aren’t capable of killing as many microbes as their surgical counterparts, and may also contain user-friendly emollients that may increase acceptance but decrease effectiveness.
How have surgical hand rub formulations been made accessible?
For the spay neuter veterinarian (or any veterinary surgeon) with limited budget, these modified formulations sound amazing: affordable, simple, effective, used safely in human surgery all over the world. But as soon as you look at the front page for necessary ingredients, the task gets daunting. Where do I find 99.8% pure isopropyl alcohol or 96% ethanol? What if I don’t need 10 liters at a time? What if there was a way I could make the same end product as in the modified hand rub formulation paper, but entirely out of ingredients I can buy over the counter at the local Walmart?
So I started doing some math and realized that I could mix bottles of two standard concentrations of drugstore isopropyl alcohol to make the 80% (volume/volume) (equivalent to 75% weight/weight) isopropyl alcohol recommended by the modified formula article without ever having to add water to the formulation. By using commercially available pre-measured sizes and concentrations of alcohol, the process of mixing is super simple– once I’ve mixed the alcohol, I use syringes to draw up and add the appropriate amounts of peroxide and glycerol.
Glycerol may be sold over the counter as Glycerin. It is the same product. One bottle will last you quite a while.
Here is the final formulation:
Modified World Health Organization isopropyl alcohol surgeon hand rub
1 quart (946 mL) 91% isopropanol
1 pint (473 mL) 70% isopropanol
62 ml H2O2
10.8 mL glycerol (also called glycerine)
Mix all ingredients together–I use a clean gallon jug for mixing and storage of the formula, and dispense into a repurposed hand sanitizer dispensing bottle for daily use.
Yield 1492 mL 79.9% (v/v) isopropanol with 0.1246% H2O2 and 0.724% glycerol
Results
I’ve been using this hand rub formulation for several years now. Of course, as with any waterless hand rub or scrub formula, it’s important that you have removed any gross contamination (in all senses of “gross”) from your hands before using the formula.
I have appreciated how easy it is to re-scrub compared to when I used water and chlorhexidine scrub to prep my hands for surgery. I don’t re-scrub between each surgery, but I will if I break sterility during my surgery day or if the indoor temperature is hot and my sweaty hands won’t go into my non-powdered surgical gloves. The isopropyl alcohol smell with this formulation is strong, so be ready for that. The skin on my hands hasn’t been bothered by the formulation and is actually less dried out than when I used chlorhexidine scrub, even though I use this product more often (again, because of the simplicity of scrubbing out and scrubbing in).
This year I’ve been thinking a lot about academic publishing: the process, access, and rights, the built-in delays. If you’ve been following this blog, you know I’ve had two articles published this year in peer-reviewed academic journals (see here and here). While I’m proud and excited to have been able to get my articles published, it’s also led me to contemplate some things that aren’t ideal about the current world of academic publishing.
Some background
Academic journal publication may be open-access or subscription-based. With open-access publishing, the article is available for free online to any reader. While this sounds fabulous for everyone—readers read for free! more people see my article!—the expenses of operating such journals are payed for using publication fees. That means that the authors of the paper have paid a fee to the publisher—from a few hundred to a few thousand dollars, from what I’ve seen—in order to submit their article. For those working for institutions, these fees may be paid for by the institution. For grant-funded studies, grantors may pay the fees. For those of us doing research on our own, these fees are a substantial barrier.
There has been a proliferation of open access journals with the internet, and credibility varies from highly reputable to highly questionable. A sting by Science Magazine several years ago revealed some serious lack of review at many (though not all) of these new journals. So while publication in a reputable peer-reviewed journal (whether open access or subscription) lends real credibility, publication in a similar-looking but sketchier journal doesn’t actually add any value or legitimacy to the content.
For subscription journals, the process is free to the authors, since the cost of publication is paid by the subscribers. The problem then becomes providing access to all the people who would be interested in or would benefit from reading the article. Different subscription content journals have different rules about how articles may be shared. In some journals like Anthrozoös, authors are allowed to publish the accepted version (not the formatted, final version) of the manuscript on their own website (as I did) or academic repository and share a limited number of free links to the article. In other journals like JAVMA, the subscription-only content is much more restricted and any sharing requires permission.
The Delays
There can be quite a delay in getting research published in subscription academic journals. Open access journals generally have faster times to publication, perhaps because their online-only format is not space restricted, and no hard-copy printing and distribution system is needed. The delay in getting research published can mean that data may be out of date and useful findings are withheld from readers, perhaps even for years. “Years” may sound extreme, but it took 2 years 4 months after submission—1 year and 8 months after acceptance— before our JAVMA study was finally published last month. From what I understand this may not be unusual for subscription academic journal articles.
What’s missing from “the literature”
Every good research publication tells a story, and every research study collects data that may be interesting but are tangential to the story. Perhaps data are collected as a step in an eligibility and randomization process or as background information, or surveys contain fields that are never analyzed. Comparisons that could be made aren’t. Information that exists is never shared.
And what about quick, small studies? Student research, or small independent surveys? When do these ever see the light of day?
What if there was a place where we could publish those bits and pieces*, the small studies, the “spin off” version of the main show? Someplace without the expense or delay of current academic publishing, where the research may just be interesting if not always deeply meaningful or revolutionary. Or, if not a single place or site, then a new standard convention of academic knowledge-sharing.
And so I have created: theJournal of Incidental Findings and Freelance Inquiry (JIFFI), an imaginary publication that exists right here. It is fast and free, reviewed by my peers after publication. No study too small or scope too narrow. (Also, it took me an entire morning of cat spays to come up with that journal name and acronym)
Of course the internet is a place with massive quantities of buyer-beware information – but is that any worse than never-shared information moldering on a floppy disk? Or for that matter, expensive publication in a sketchy/ poorly run open access journal? It seems to me that getting information out there is more valuable than waiting to figure out a more “legitimate” forum in which to publish.
In that vein, I will be aiming to use this space to publish some of the previously unpublished bits and pieces that I think could be helpful to some people. Some of my previous posts, such as Surgery Packs and Suture in HQHVSN would “qualify” for JIFFI as well, and I’ll create a tag and category for these posts on this site.
I’d love to see other people who do research, whether formally or informally, get their small or incidental results out there for others to use too.
*Credit for the initial idea of a journal that would publish these “other” findings goes to my recent co-authors Jan Scarlett and Julie Levy, from a conversation in early 2016 as we were preparing the final version of our recently published JAVMA study.
Meanwhile, how does Moe even see past those whiskers? They’re almost enough to distract from the excessive number of toes.
The data for the study comes from surveys of thousands of clients bringing their cats or dogs to stationary spay neuter clinics all over the US over the course of one year.
If you were lucky, you may have seen me presenting the results of this study in 2015 at the North American Veterinary Conference or at the SAWA/National Council on Pet Population research day. Below, I’ll describe the study using some graphics from these original presentations (which are more colorful and varied and less copyrighted than those in JAVMA). We have a press release available on the Million Cat Challenge website too, which you might want to check out to learn more about the study and its interpretation.
The Study Clinics
We wanted to be sure to include clinics and clients from all over the US, in case there were regional differences in the types of clients or pets who use spay neuter clinics. Similarly, we wanted to be sure to include different times of year, in case there was a seasonality to clinic patients. In order to make sure we chose clinics from all over, we divided the US into 4 regions (actually, the Census Bureau did the dividing) and tried to get proportional representation from each region. Here is what that looked like:
Once we selected the clinics, we asked them each to survey all clients bringing cats or dogs to the clinic during four specific weeks over the course of a year. Clients would fill out a survey for up to two animals and answer questions about themselves as well as about their pet. We didn’t ask feral cat caretakers or shelters and rescues to fill out surveys, and we also didn’t get surveys from clients whose pets arrived at the clinic in transport vehicles.
The Animals
Overall, about half of the 12,901 animals that clinics saw during the study weeks were brought to the clinic by owners, and the other half consisted of shelter animals, ferals, and animals arriving by transport vehicle.
Again, only the drop-off at clinic animals were eligible for the study. About 2/3 of these animals (4,056 animals) ended up being included. Among those, there was a pretty equal split between males and females, and between dogs and cats.
The ages of animals varied, but overall, felines were being altered younger than canines:
The age and species composition varied somewhat around the US, with the Northeast having more cats, and the West having more dogs.
Among the adult female patients, 28% of the cats and 17% of the dogs had had a previous litter. Most of these cats (66%) had only had one litter, whereas just over half of these dogs (51%) had two or more litters before being spayed.
Previous Veterinary Care
The animals, especially the cats, had limited previous exposure to veterinary medicine. For most of these pets, this was their first time seeing a veterinarian.
Even more alarming from a public health perspective, very few of the cats over 4 months old had ever received a rabies vaccination. The dogs were more likely to have had a rabies vaccine, which we attributed to licensing requirements and the availability of rabies vaccine clinics.
The Clients
We asked clients to share their annual household income, and found that most clients’ incomes fell below the national median household income, and below each of the regional median incomes. This was true whether they were bringing dogs or cats or both to the clinic, although cat owners tended to have lower income than dog owners:
We found similar income distributions among all regions, with the lowest client incomes in the Northeast, where the clinics also see more cats:
The Reasons
We asked clients why they were choosing to get their pets neutered now, and also why they chose to come to the spay neuter clinic. They were allowed to choose as many answers as they liked.
Population control, avoiding heat, and behavioral reasons were the top choices for both cat and dog owners when asked reasons for getting their pet neutered now:
Cost, recommendations, and reputation were the top reasons why clients chose the nonprofit spay neuter clinic instead of other options:
The Takeaways
Even though most of the study clinics didn’t screen for income, the majority of the people and animals that they served fell into the low income demographic, with about a quarter of clients falling below the poverty line. We can also see from the survey results that the majority of these pets had never seen a veterinarian before. For the most part, nonprofit spay neuter clinics are reaching the people who most need their services and who would likely not get those services elsewhere, or who would struggle to pay for those services if they did receive them elsewhere.
Penniless Pussycat is in need of a low cost clinic
Also, remember that client-owned animals only made up about half of the patients that participating clinics saw during the study period. These clinics also spayed or neutered thousands of homeless animals during the study weeks: remember that 24% of the clinics’ patients were shelter animals, and another 18% of the patients were feral cats. Even though these animals weren’t included in the study, they are a huge part of the work that nonprofit spay and neuter clinics do and should always be factored in to the value of what clinics provide.
As a spay neuter vet, I was also happy to see that clinics enjoyed a good reputation among clients such that reputation and referrals from friends were two of the top three reasons clients gave for choosing the clinic. So clients feel that they are getting not just an affordable service, but a high-quality service as well.
Within the last few months, I suddenly have become middle aged, or at least my eyes have. I’ve been using readers (“cheaters”) the past few years occasionally for reading, and had found them necessary during feline physical exams in order to age the little kittens by their tiny incisors, but it was only this spring that I found that I needed my glasses in surgery as well. Perhaps I could have held out longer if I used swaged-on suture, but threading the needle with my cassette suture was getting challenging.
So I put on my glasses for surgery and could immediately see nothing though the fog. That was an easy fix though– fog-free mask, fitted to the bridge of my nose. These masks have a foam strip along the bridge of the nose that has the added bonus of absorbing sweat on those 80+ degree surgery days.
Yes, they actually work! As long as you shape the metal strip to the bridge of your nose.
But then came the next problem. When I put on my plastic $5 reading glasses and started surgery, I found that, in order to look through the lenses, I had to bend my neck downwards at a greater angle than usual. If I tried to look down with just my eyes, I ended up looking at the bottom of the plastic frame and the small space below it rather than through the lens.
Surgery with no glasses. My neck is bent at a 35-36 degree angle.With my plastic framed reading glasses, I have to bend my head more in order to avoid having my vision interrupted by the lower frame of the glasses. My neck is at 40 degrees.
The extra angulation really seemed to be uncomfortable for my neck and shoulders, so I tried sliding the glasses further down my nose, “geezer style.” That improved the angle of my neck, but it was a little uncomfortable across my ears and definitely insecure. The glasses would slide on the slick surface of the mask, and there was even one time when they slid off in the middle of surgery. Fortunately I was able to catch them in my hand before they landed in the middle of a cat.
Plastic glasses worn far down on my nose, “geezer style.” My neck angle is just 34 degrees, but the glasses slip.
So I did what all good modern humans do: I appealed to the internet for help. Or, specifically, to some spay-neuter and shelter veterinarian groups that I’m a part of. Suggestions ran the gamut from progressive lenses to loupes to better patient positioning.
Loupes
The idea of wearing loupes in surgery has intrigued me. Ergonomists often suggest them as a way to decrease neck angle, and it seemed that, if I was requiring corrective lenses anyway, I might as well use something that would further help with my neck angulation.
But the thing about loupes is that even if you find ones that you can adjust to a very steep declination angle, it’s still your eyes (or, your extraocular muscles) that are making the adjustment. There is no fancy prism or deflection in the lenses of the loupes– they just force you to turn your eyes downward in order to view through the magnifying lenses. So in that way, it seems that there is nothing that loupes can do regarding angulation that can’t be achieved with your eyeballs and a regular pair of glasses. It’s just a matter of getting those glasses low enough.
Loupes can be really helpful if you need that extra magnification. Here, Dr. Sandy uses a flip-up loupe (plus face shield and LED light) while doing dental work on a dog.
Of course, if you need the extra magnification, loupes can be great. Dr. Sandy let me try on a few pairs of hers and I found the magnification to be way more than what I wanted for spays, and the field of view to be much narrower than I would like. She also told me that there would be about a month’s learning curve in using them. So, I decided to avoid loupes for now.
Progressive Lenses
It turns out that it’s possible to get progressive lenses that have no correction on top, but that have a near-distance correction on the bottom. Since I don’t need glasses for distance vision, I hadn’t considered progressives. But this would be a way to have lenses that allow close vision for surgery, and that have the clear glass on top so I could see the monitors or look at the other people in the room.
Generally progressive lenses would require a prescription, but a local eyeglass store suggested it may be possible to find them online without a prescription (since they are essentially drugstore readers with glass above).
Half Glasses
But it seemed to me that progressive lenses with no correction on top would just be a way to avoid always looking over one’s glasses at people. So why not find some half glasses designed to fit as low on the bridge of my nose as possible? That way when I look down I’m still looking through lens, and when I look up I’m looking over the glasses.
Half glasses. Don’t you wish you could be this cool? Also, they go well with grey hair.
I like the light weight and thin metal construction of these glasses. The ear pieces are fine enough that they don’t get all mixed up with my surgery cap and mask ties and irritate the tops of my ears. And the bridge of the glasses sits right down on my nose so that they are as low as possible. Basically, they are like the bottom half of a progressive lens. This sort of glasses is available online, or, as luck would have it, at the South Station Terminal in Boston, where I found mine.
Wearing half glasses in surgery. My neck is at 37 degrees and my glasses aren’t sliding off my face.
So for now I’ve solved my vision-in-surgery problem. Maybe once I reach the age where my vision stops changing, I’ll spring for a pair of progressives, but for now I’ll be looking over my glasses at you.
View from the top of Mount Cube in NH last week. This may have been too much of a climb for 7 weeks post-op but the view was worth it.
Three weeks ago, I went to see my surgeon, the ob/gyn who performed my hysterectomy last fall. The last time I had seen her was in January, the day my complication was diagnosed. In my mind, though, she had been present throughout my various procedures and recovery, even after the urologists took over my care and our only continued connection was through what I sent to her. I had talked with her once after the urologists placed my drains, and after that, emailed (my preference, a consequence of my lifelong terror of the phone). I had sent her my article during those first weeks, and she emailed back that it described her own experience. Time had separated us more by the time of my visit, but I kept her up to date with plans and surgery reports.
We had become entangled by concern as I worried as much over her experience as my own. So to the extent that my meeting with her last month was a conclusion, I was sad to see her go, and I felt unaccountably lonely that day. This long, shared experience, that wasn’t really shared but perhaps co-imagined, had made me want to cling to that connection. But yet, what to do with it? And the awkward: she is not my colleague; we are not friends.
And yet, as I spoke with her, I found myself wanting to ask questions like a colleague/ mentor/ teacher/ friend more than as a patient. What did you see, what did you do, what (if anything) have you changed? And to explain what I had surmised, technically: that my injury was subtle and would have been hard to detect at the time of surgery, my ureter at first patent, then after 20 days blocked, then, soon after, ruptured. That my best guess is a devascularization injury to the ureter that caused it to deteriorate slowly. That, at the end of surgery before closing, everything might have looked normal.
Long before I had my surgery, I knew that she was a low volume surgery provider. I know the data: that, statistically, lower volume surgeons have higher complication rates. I knew it before my own surgery and thought but didn’t seek to make a change. I probably could have asked to go to the large referral hospital in the same town– I certainly could have withstood the awkwardness of the request. Perhaps I partly thought that the odds were still (and ever) in my favor, as they were. Statistical risks don’t get you far as an individual. I liked her hands.
Why would high-volume surgeons have lower complication rates than low-volume surgeons? Partly it may be the development of the manual, physical skill of surgery. Practicing a fine motor task leads to greater skill, and perhaps in this case the more you practice the greater the skill. But I think also that there is an accumulation of knowledge about anomalies and an abundance and diversity of feedback as one does surgery more often.
In some surgeries and for some complications, the feedback is immediate. This fast feedback enhances learning because the error and the consequence are memorable and easy to connect. These complications may be painful or scary or intense in the moment, but the connection between cause and effect is never in question.
Immediate Feedback. Do not pet the pussycat’s belly when she is on catnip! (No pussycats were harmed in the production of this photo. One human was slightly sore but entirely to blame.)
In my case, the feedback was long delayed. By the time I had my ureter reimplantation surgery, suture from the original surgery had dissolved, scar tissue had formed, and the original injury was completely obscured. Even worse, the only way that my surgeon knew about my progress and the only way she saw my surgery report was that I sent these things to her. Otherwise she would have had no follow-up or feedback at all after the complication had been recognized. Without my efforts, her knowledge of my complication would have been limited to the findings on the day of its discovery.
This lack of feedback feels perverse. It is the consequence of privacy laws and complicated, diverse, and poorly interconnected systems in medical care. But it is not the way to support doctors or to improve the quality of care they provide.
Atul Gawande describes the need for a more robust feedback loop in medical care in this Freakonomics Podcast episode (and talks about how immediate feedback interventions– like the use of anesthesia in surgery–catch on much more quickly than delayed-feedback ones — like antisepsis).
I wish I could end this post with some brilliant solution to this lack of feedback, but for now, I only have the observation. I suspect the problem is less prevalent in veterinary care both because of less emphasis on privacy (no HIPAA for pets), and because of less complexity and specialization in the systems of care. I’d like to think that Atul Gawande is right when he says in this podcast that we’re in the MS DOS phase of medical information systems, and that at some point in the future, systems will be integrated enough to provide medical providers with the feedback they need.
As for me, other than being determined to climb bigger mountains than my current fitness level would indicate, I am doing well. My incisions are all healed and my various tubing has all been removed. Other than follow-up with occasional ultrasound exams, I’m done with this whole process of complication and repair.
I’ll end with a few more pictures from my hike last week on Mt. Cube (scroll back up to the beginning of this post to see the panoramic view from the mountaintop).
A smaller view from Mt. Cube. A wood frog.Another small view from Mt. Cube. Rhodora (Rhododendron canadense) is bright and showy, but only ankle height.
Today’s post is a little different: I’m sharing the results of a survey of HQHVSN veterinarians and their choices in instrumentation and suture for spay and neuter surgeries.
Instruments and suture are the interface between us and our patients, and are integral to every aspect of our surgical performance: our efficiency, our comfort, and our precision. While I know of other authors who have speculated on the “typical” spay pack or neuter pack in private practice or in HQHVSN, I didn’t know of any study of what is actually used out there in practice. So, I designed a study and am publishing it here.
Methods
An 8-question multiple choice and matrix-type question survey was designed in Survey Monkey. The first 3 questions included separate answer grids for numbers and types of instruments and drapes in dog spay, dog neuter, and cat spay packs. Respondents were then asked about usage of suture cassettes versus suture with needles attached (swaged-on), suture type preferences, and finally suture size preferences for different surgery types and patient sizes.
A link to the survey was distributed to the HQHVSNvets Yahoo Group and was posted on the Association of Shelter Veterinarians Facebook group. Reminders were distributed on 5/1/18. Responses were collected from 4/26/18 to 5/9/18, and results were downloaded into Microsoft Excel for analysis.
Results
There were 83 completed responses to this survey. Of those, one veterinarian performed only cat surgeries, whereas the other 82 performed cat and dog surgeries.
Surgery Packs
Of the 82 veterinarians working with cats and dogs, 12 (14.6%) had only one type of surgery pack that they would use for any of the different surgeries. In addition, there were others who used the same pack type for multiple types of surgeries, but not for all surgery types. Six (7.3%) used the same type of packs for cat spays and dog neuters, but different pack types for dog spays. Two (2.4%) used the same types of packs for dog spays and neuters, but a different type of packs for cat spays.
There were a median of 11 instruments in each dog spay pack, with a range from 6 to 18. All dog spay packs contained a spay hook, a thumb forcep, scissors, and a needle holder. Of the needle holders, 79 (96.3%) were Olsen Hegar and only 3 (3.7%) were Mayo Hegar. Of the scissors, 39 packs (47.6%) had Mayo scissors, 62 (75.6%) had Metzenbaum scissors, and 3 (3.7%) had Operating scissors. Twenty-one dog spay packs (25.6%) contained both Mayo and Metzenbaum scissors. Of the thumb forceps, 70 dog spay packs (85.3%) contained Adson Brown forceps, 16 (19.5%) contained rats tooth forceps, and 8 (9.7%) contained Adson tissue forceps. Some packs contained more than one thumb forcep. One respondent commented that they used whichever thumb forcep type had been donated.
The packs with only 6 instruments did not contain any hemostats; all other dog spay packs (98.7%) contained at least one type of hemostat. Seventy-five (91.4%) contained Kelly or Crile type hemostats (1-5 per pack), 68 (82.9%) contained Carmalts (1-4 per pack), and 63 (76.8%) contained mosquito hemostats (1-4 per pack). Some respondents commented that additional instruments including Carmalts or Rochester Pean forceps were available in separately wrapped packages for use as needed on dog spays.
Additional instruments included in dog spay packs were towel clamps in 49 packs (59.8%), with 1-4 towel clamps present per pack, and scalpel blade holders in 32 packs (39.0%). One respondents’ dog spay packs included a Dowling Spay Retractor, and two included Allis Tissue Forceps.
Seventy-five packs (91.4%) contained drapes of some type, with 51 (62.2%) containing cloth drape and 27 (32.9%) containing paper drape (of these, 3 contained both paper and cloth drape). Some respondents also commented that their packs contained huck towels. One respondent commented that drapes are wrapped separately; this is likely to be the case for all clinics where drapes are not included in the packs. 52.9% of the packs containing cloth drapes also contained towel clamps, whereas 70.4% of the packs containing paper drapes also contained towel clamps.
There were a median of 10 instruments in each cat spay pack, with a range from 6 to 15. All cat spay packs contained a spay hook, a thumb forcep, and a needle holder. Of the needle holders, 79 (95.2%) were Olsen Hegar and only 4 (4.8%) were Mayo Hegar. Of the thumb forceps, 70 cat spay packs (84.3%) contained Adson Brown forceps, 13 (15.6%) contained rats tooth forceps, and 8 (9.6%) contained Adson tissue forceps. Some packs contained more than one thumb forcep.
Of the scissors, 28 packs (33.7%) had Mayo scissors, 62 (74.7%) had Metzenbaum scissors, and 5 (6.0%) had Operating scissors. Thirteen cat spay packs (15.6%) contained both Mayo and Metzenbaum scissors, and two packs (2.4%) did not contain scissors.
The packs with only 6 instruments did not contain any hemostats; all other dog spay packs (98.7%) contained at least one type of hemostat. Seventy-seven (92.8%) contained mosquito hemostats (1-4 per pack), 67 (80.7%) contained Kelly or Crile type hemostats (1-3 per pack), and 40 (48.2%) contained Carmalts (1-3 per pack). One contained two Rochester Pean forceps.
Additional instruments included in cat spay packs were towel clamps in 42 packs (50.6%), with 1-4 towel clamps present per pack, and scalpel blade holders in 31 packs (37.3%).
Seventy-nine packs (95.2%) contained drapes of some type, with 51 (61.4%) containing cloth drape and 29 (34.9%) containing paper drape (of these, 3 contained both paper and cloth drape). Some respondents also commented that their packs contained huck towels. One respondent commented that drapes are wrapped separately; this is likely to be the case for all clinics where drapes are not included in the packs. 45.1% of the packs containing cloth drapes also contained towel clamps, whereas 58.6% of the packs containing paper drapes also contained towel clamps.
There were a median of 8 instruments in each dog neuter pack, with a range from 1 to 15. No instrument type was present in every dog neuter pack, although all but one contained at least one hemostat. Two dog neuter packs (2.5%) consisted of only one mosquito hemostat. Sixty (74.1%) (including the two above) contained mosquito hemostats (1-4 per pack), 60 (74.1%) contained Kelly or Crile type hemostats (1-3 per pack), and 34 (42.0%) contained Carmalts (1-2 per pack).
Seventy-eight of 81 dog neuter packs contained needle holders: 74 (91.4% of packs) contained Olsen Hegar and only 4 (4.9%) contained Mayo Hegar. All packs except the single hemostat packs contained thumb forceps; 68 (84.0%) contained Adson Brown forceps, 9 (11.1%) contained rats tooth forceps, and 5 (6.2%) contained Adson tissue forceps. Some packs contained more than one thumb forcep.
Fifty-seven (70.4%) dog neuter packs contained scissors: 28 (34.6%) had Mayo scissors, 38 (46.9%) had Metzenbaum scissors, and 3 (3.7%) had Operating scissors. Twelve dog neuter packs (14.8%) contained both Mayo and Metzenbaum scissors, and 24 packs (29.6%) did not contain scissors.
Additional instruments included in dog neuter packs were towel clamps in 39 packs (48.1%), with 1-4 towel clamps present per pack, and scalpel blade holders in 26 packs (32.1%). Twenty-one (28.4%) dog neuter packs contained a spay hook, likely because these packs were not assembled specifically for dog neuters.
Seventy-two packs (88.9%) contained drapes of some type, with 48 (59.3%) containing cloth drape and 26 (32.1%) containing paper drape (of these, 2 contained both paper and cloth drape). Some respondents also commented that their packs contained huck towels. 41.7% of the packs containing cloth drapes also contained towel clamps, whereas 57.7% of the packs containing paper drapes also contained towel clamps.
Suture
Suture type and packaging
Eighty-two veterinarians responded to the question regarding the suture packaging that they used most commonly. Over half of respondents used swaged-on suture all the time or most often, although 42% used suture from a cassette all or most of the time.
“Other” responses included “Cassette for internal ligatures and large spay closures. Swaged on for small spay closures” and “Swaged on when I need a needle, I use Cassette suture to ligate the pedicles and uterine stump”
Suture composition
Eighty-one veterinarians responded to the question about what suture composition they used for each surgery. Veterinarians showed a strong preference for synthetic monofilament suture for all surgery types, with all but one respondent (98.8%) using this suture type for at least some surgeries, and 75 respondents (92.6%) using only synthetic monofilament suture in all surgeries.
The one surgeon who did not use any synthetic monofilament suture used synthetic braided suture in all surgery types.
Two surgeons (2.5%) used stainless steel in cat spays; both of these veterinarians also used synthetic monofilament suture in cat spays, and one also indicated that they use chromic gut in cat spays. This surgeon commented that they used stainless steel for uterine body ligation in pediatric kittens.
Three surgeons used chromic gut suture in at least some surgeries. All three used chromic gut in dog spays; 2 used it in dog neuters, and one used it in cat spays. In all cases, veterinarians who used chromic gut in a surgery type also used synthetic monofilament suture in that surgery type. One of the surgeons who uses chromic gut in dog spays commented that they “ligate pedicles with 2 chromic gut for most dogs >40# (great knot security),” but close the abdomen with synthetic monofilament suture.
No surgeons used synthetic nonabsorbable suture in any surgery type in this survey.
Suture size
Eighty two surgeons responded to questions about their suture size preferences. For kitten spays, 33 (40.2%) used 4-0 suture while 55 (67.1%) used 3-0 suture. Some surgeons responded with both suture sizes for kittens. For adult cats, only 3 (3.7%) surgeons used 4-0 suture while 76 (92.7%) used 3-0 suture, 13 (15.9%) used 2-0 suture, and 3 (3.7%) used 0 suture. Some surgeons responded with more than one suture size for adult cat spays. Some surgeons commented that they used the larger sizes of suture specifically for uterine body ligation in the pregnant, enlarged, or diseased uterus, and smaller suture for body wall and subcutaneous closure.
In dogs, suture size preferences were more variable. For the smallest puppy spays under 10 pounds, 3-0 was preferred by 80.5% of respondents. For puppies 10-20 pounds, respondents were nearly evenly split between 3-0 and 2-0 suture. By the time puppies were over 30 pounds, 2-0 suture was preferred by most veterinarians.
For adult dog spays, suture size preferences also varied considerably, with 3-0 preferred for the smallest dogs under 10 pounds, 2-0 for those 10-40 pounds, 2-0 and 0 nearly equally selected for 40-50 pound dogs, and 0 preferred for those over 50 pounds. Some surgeons commented that they used more than one size of suture in larger dogs, with a large size suture used for ligations and body wall closure, and smaller suture selected for the subcutaneous and subcuticular closures. This accounts for the persistence of small suture sizes even in the largest dog spays.
Adult dog neuter suture size preferences were somewhat smaller than those preferred for spays. For dogs under 20 pounds, 3-0 was preferred, with 2-0 for those 20-50 pounds, 2-0 and 0 nearly equally selected for 50 pounds and up. Some surgeons commented that they used more than one size of suture in larger dogs, with a large size suture used for cord ligations, and smaller suture selected for the subcutaneous and/ or subcuticular closures and for ligation of subcutaneous bleeders. This accounts for the persistence of small suture sizes even in the largest dog neuters.
Not all veterinarians use suture on adult dog neuters. One respondent commented, “Rarely use suture, autoligate most cords and glue the scrotum. Only do ligatures on very large cords, only suture very pendulous scrotums.”
Discussion
Instrument preferences
Certain instrument preferences are identifiable within this data. A large majority of veterinarians chose Olsen Hegar¹needle holders over Mayo Hegars. Olsen Hegars allow increased efficiency by allowing the surgeon to cut suture ends after knot tying without requiring them to exchange needle holders for scissors. While there is some risk with Olsen Hegar needle holders of inadvertently cutting suture while attempting to grasp, this consequence may be reduced with attention and practice. In addition, since spay and neuter surgeries do not require suturing in deep cavities, it is less likely that suture will be inadvertently cut, as this occurs most often when visibility is poor and when suturing in a restricted space.
Fewer than half of the surgery packs contained scalpel blade handles. While it has been suggested that use of blades on scalpel handles is safer than using unattached blades, other literature suggests that about 10% of scalpel injuries occur during disassembly of the blade from the handle. Spay neuter veterinarians may choose to eliminate scalpel handles from their packs due to the additional time required to assemble and disassemble the blade and handle, and the ability to make smaller and quicker movements with the blade alone than with the blade with handle. Disadvantages of using unattached scalpel blades could include the increased likelihood of losing track of the blade within the surgery field and potential injury due to lack of visualization of the blade, or due to the blade slipping in the fingers.
Towel clamps were present in about half of the packs, and were more likely to appear in dog spay packs than in other packs. In all surgery pack types, towel clamps were more likely to be included in packs with paper drapes compared to cloth drapes. This suggests that the draping qualities of cloth drapes allow these drapes to remain in place more readily without clamping, whereas the stiffer, less-conforming nature of paper drapes means that veterinarians are more likely to choose to use towel clamps. In addition, some veterinarians or clinics may choose not to use towel clamps on cloth drapes in order to avoid damaging the reusable cloth and shortening the life of the drape material.
Surgery pack sizes and contents varied considerably. For clinics with many surgery packs, the expense of purchasing larger packs and the labor required to reprocess the larger number of instruments could both be substantial. For clinics purchasing or assembling new packs, it might be worth considering assembling smaller packs and providing separately wrapped and sterilized additional instruments for use when needed, rather than including greater numbers of instruments in each pack.
Sutures
The use of cassette suture by nearly half of the respondents may have been a nod to economy, but also would have facilitated the use of different suture sizes in different parts of the surgery or different layers of the closure. Surgeons may be hesitant to open a new package of suture simply to place one or two ligatures or appositional sutures, but may be more willing to do so when a small amount of suture can be removed from a cassette for that purpose. The respondents who use both cassette and swaged-on suture may also be taking advantage of this multi-size strategy by using cassette suture for ligations, where no needle is needed, and swaged suture for locations where suturing with a needle is required.
Suture type selection was unsurprising, with most respondents preferring synthetic monofilament absorbable suture throughout their surgeries. Since no surgeons indicated the use of nonabsorbable synthetic suture, it can be inferred that none are placing external skin sutures in their spay and neuter patients. This may be different from the private practice setting, where patients may be expected to return to the veterinary clinic for skin suture removal, a practice which may be impractical or impossible in the HQHVSN setting.
Limitations
This survey only asked about instrument and suture preferences. While it is possible to make some inferences about technique from the choices of instrument and suture and from comments left by respondents, it is not truly possible to know from these questions what techniques HQHVSN vets are actually using. This information would be interesting but was beyond the scope of this study.
The survey respondents were self-selected and consisted of veterinarians who use electronic means (Yahoo group or Facebook group) to connect with other veterinarians in shelter or spay neuter practice. These veterinarians may or may not be typical of veterinarians in these types of practice– thus, the results may not be reflective or representative of all spay neuter practice. Furthermore, responding veterinarians may be using packs and suture types which have been selected by others (practice managers, previous veterinarians) and which do not necessarily reflect their own preferences.
Conclusion
Surgical instruments and suture are an important factor in the physical ergonomics of surgery and represent the interface between veterinarian and patient. Selection of these tools will affect the efficiency, comfort, and performance of the surgeons who use them. This survey demonstrated some areas of consistency among surgeons, as well as substantial variability in other areas, but I hope that at least some clinics and veterinarians find this information useful.
Footnote
Bushby calls the Olsen Hegar needle holder a “spork.” I think this is really funny and accurate, despite my love for my Olsen Hegars.
No tropical beaches during my “vacation” – just good old Vermont mud season.
As I prepare to go back to work tomorrow after my 20-day “surgical vacation” (see here for why I needed a surgical vacation), I have been reminded of one of the reasons I first became interested in human factors and ergonomics in veterinary practice: our willingness to work while physically injured or unwell. Eleven years ago I was talking to a vet who bemoaned the fact that the technicians and schedulers at the spay neuter clinic where she worked weren’t taking into account that her surgery speeds were slower because she had broken her arm only the week before and was working with a cast on her arm. I was in awe at her toughness, but then recalled working the previous fall with a broken finger (just a small fracture of an extensor process, and just my fourth finger, not an “important” one), and two years later thought little of returning to work the week after my own hip fracture.
There are plenty of good reasons for our tendency to work through injury and physical compromise. Whether in spay/neuter, shelter, or general practice, many of us work in small practices as the only veterinarian, or one of only a few veterinarians. Missing work due to injury or illness only means more work upon return, disappointed clients, patients left untreated, and loss of revenue (for the practice, and often for the individual as well). We often have little or no provision to cover for our absences, so we feel pressured to come back.
One interesting study found lower rates of musculoskeletal discomfort but higher rates of missed work due to discomfort among veterinarians working in regulatory practice compared with clinical practice—perhaps a reflection, as much as anything, on their ability to get coverage and financial compensation during their absence.
It can be boring sitting at home recovering, unless you have a Cat Butt Coloring Book and a mystery novel.
Our tendency to work while injured or physically compromised combines nicely with our tendency to self-treat (see here and here). A 1988 study on veterinarians and trauma states: “Self-treatment of injuries was common. Four per cent of veterinarians reduced their own fractures and dislocations, 20% sutured their own lacerations, and 67.5% self-administered antibiotics.” In instances of bite wounds, this self-treatment may lead to greater complications; as far as I can find, the consequences of veterinarian self-treatment for other injuries hasn’t been studied.
In my current case, of course, self-treatment wasn’t an issue or an option (though I did have more than one spay-neuter veterinarian suggest that they should have been the one to perform my initial hysterectomy surgery).
In any case, I’m fortunate because, other than a 4-week restriction against lifting, I am physically capable and ready for my return. I was able to schedule the time off that I needed to heal and didn’t need to push myself to go back as soon as I could walk or drive. Now, it’s time to get back to work!
For those of you who are curious, my own surgery on April 10th was a ureter reimplantation surgery with a psoas hitch. For a do-it-yourself, detailed description of the surgery and some useful illustrations of the psoas hitch, see this paper. Basically, in order to prevent tension on the new connection between the healthy part of the damaged ureter and the bladder, the surgeon tacks the bladder to a nearby hip flexor located along the spine. What results is a bladder that slants to the side of the injury.
Psoas hitch illustration from the paper Stein, Raimund, et al. “Psoas hitch and Boari flap ureteroneocystostomy.” BJU international 112.1 (2013): 137-155.
Several days after surgery, once I started moving around more, I could feel the pull and soreness of my psoas muscle, especially when I made a big step up with my left leg or put my left leg across my knee to put on a sock or tie a shoe. The feeling of having a strained muscle is still there a bit, but much less than it was a couple weeks ago.
A pikachu visits me in the recovery ward. I don’t think the nurses saw her.
I stayed in the hospital for 3 nights, which was a day longer than expected, but with my mild postoperative anemia and my wife showing the first symptoms of what turned out to be a case of anaplasmosis on the same day as my surgery, it seemed wise to spend the extra night. (Never fear, a quick diagnosis and the wonders of doxycycline made quick work of the tick borne menace).
My Foley catheter was removed 10 days post-op, after a cystogram showed no bladder leaks, so now, for the first time since January, I no longer have to carry around a bag of my own urine. Small victories…
My first week back at work after my nephrostomy and abdominal drain were placed, I had a major wardrobe malfunction. I was wearing a leg bag on each leg, strapped to the front of my thigh with elastic bands. I was kneeling on the floor, examining a large, handsome hound dog, and I felt a dampness spreading across my left knee. My vet tech and the shelter staffer who were helping us saw it too.
Of course, it’s not too unusual to end up with damp spots on my clothing at some point during exams. Puppy pee, slobbery dogs, wet or muddy paws.
I said, “That wasn’t the dog”
I could feel the urine still running out of the leg bag. It had been pretty full, and I don’t know if the dog had bumped it, or if my scrub pants had rubbed against and dislodged the end cap as I knelt, or if just the pressure of my flexed thigh against the full bag was enough to push the cap off.
I stood up, laughing, embarrassed, trying to kink the end of the bag to stop the flow, but to no avail. Immediately the urine ran down my leg and filled my shoe. Someone handed me a towel and I wrapped myself in it, asked my tech to get my spare clothes out of the vehicle (pro tip: always have spare clothes in the vehicle), and ran to the bathroom to change.
I emerged from the bathroom barefoot but dry, my urine-soaked clothes and shoes stuffed into a plastic bag to launder once I got home. I slipped my feet back into the snow boots I had worn to work that morning.
“Do you want me to run those through the wash for you?” the shelter staffer offered.
“Are you sure?” This seemed a bigger imposition, and more personal, than the initial, urgent cleanup. And I was just the visiting vet, only there a day a month, not her friend or co-worker or boss.
She took the bag back to the laundry room, and by the time I was ready to go home, the clothes and even the shoes and socks were clean and dry.
Fortunately, I’m not a leader who relies on dignity or control over others to bolster my authority. I’m confident, but I joke about my weaker points and don’t mind occasionally playing the fool (or being, accidentally, made foolish).
Like most veterinarians, I had never studied leadership when I got my first job with management duties, nor later when I started my own business (Spay ASAP Inc, a nonprofit MASH mobile spay neuter clinic). Later, I was introduced to organizational ergonomics during my ergonomics masters program, and then I attended a 2-day course at Emancipet called Surgeon to Leader.
One of the topics we discussed was the difference between management authority and leadership authority. Management authority is structural: it comes from a job title, and allows you to say, “because I said so.” Leadership authority is granted by each individual: it happens regardless of whether you have managerial power. With leadership authority, people follow because they want to, not because they have to. They follow because they believe that together, you will achieve something worthwhile that neither of you can achieve alone.
In my own workplace, I have management authority over only one other person: the veterinary technician who I’m paying to be there. But I strive for (and can only function with) some level of leadership authority, to inspire those who work for other entities and those who volunteer to believe that what I’m asking them to do is useful and worthwhile. I could aim to gain that leadership authority by inspiring awe, but like the awkward alien in the Gary Larson cartoon, I’d be bound to fail (or fall) eventually. Instead, I earn what leadership authority I have by working hard and allowing others to feel involved in and integral to that work.
A few days ago, a veterinarian friend emailed about how she had been fighting the perfectionism in veterinary medicine by admitting openly to staff when she didn’t know something, instead of sneaking off to look up the answers. She points out her mistakes and near misses rather than trying to hide them, seeking to emphasize that we’re all human and therefore not perfect. When she does this, she may be not only helping to break down the harmful self-imposed norm of perfectionism in the veterinary profession, she may also be making it safe for the other people that she works with to look at, talk about, and understand error as well. And by doing that, as I wrote about last time, she may actually be making her practice safer– all by being openly imperfect.
Like my friend, I also try to point out to my staff the things I could have done better when I’ve made a mistake or had a complication. Also like my friend, I find it’s easier to admit my shortcomings to others than to accept them in myself. It’s funny how, even knowing what I do about complications and coping, it feels far less shameful to be soaked in my own urine than to know that I have caused harm to an animal. And while that shame can be a short-term motivator to change (no more leg bags at work for me, only fanny packs), it’s not a productive or sustainable way to generate process improvement because it’s hard and painful to think about something shameful, so it’s hard to use the experience to analyze, reconstruct, and modify a work process.
Previous authors have spent a lot of time thinking about error taxonomy in surgery, anesthesia, and elsewhere, and while the answers aren’t always simple, they can be categorized. (The types of error that can happen in surgery are summarized nicely in this article by Cuschieri.)
Errors in execution or perception
Many surgical (and anesthetic) errors stem from differences in individual patient anatomy or physiology that reveal vulnerabilities in an existing technique or protocol—a technique or protocol that is adequate in most but not all circumstances. These can be some of the most difficult errors to identify and understand. An example might be a veterinarian who tightens the ligature around every cat’s uterine body and vessels using one pound of pressure on the first and second throw of her ligature knot. In most cats, this will be sufficient, but in a few (probably in-heat) cats, it likely will not, and those cats may bleed from the ligated vessels and perhaps require re-operation and re-ligation.
This inadequate ligature tension is an error in technique that in most cats causes no harm. In each cat, there is the possibility that it will be adequate, or not. The solution to this error would be to tie all uterine body ligatures with greater tension (say, 2 pounds of tension), or to use a cue from the patient to determine when ligature tension is adequate in that patient (such as observing tissue blanching under the ligature).
Other errors in execution in surgery may be due to lapsed attention or to a mistaken perception. Attention lapses are more plausible than one might think: proficient surgeons use habitual motions and automatic processing, rather than the more deliberate and slow techniques of the inexperienced surgeon (again, see the article by Cuschieri). This automaticity allows for efficient and minimally traumatic surgical performance and is essential to practice, but it may also allow for inattention. Often if a problem arises, the surgeon will perceive an inconsistency between her mental picture of the surgery and real life, which will focus her attention and allow her to adapt to the new surgical circumstances. If not, the problem may go unnoticed and result in a complication.
A mistaken perception may go hand in hand with automaticity or with inexperience. Anatomy varies, and the surgeon may not see what she expects to see where she expects to see it. A misidentified organ, vessel, duct, or tissue can easily be severed or ligated.
Latent (system) errors
Another type of error that happens in practice may be a systematic error, a problem in the organization and allocation of time and resources. This latent error is a gap that is present at all times, but may go unnoticed and uncorrected, especially if no harm comes from it.
Professor James Reason makes the analogy of Swiss cheese, in which each slice of cheese is a layer of defense, and it is only in certain unlucky circumstances when the holes in these layers align to allow an accident or injury to occur.
In veterinary practice, an example of a latent error might be limited or infrequent observation of patients recovering from anesthesia. In perhaps 99.8% of patients, there will be no problem if they are observed only intermittently during the period after they have begun to rouse from anesthesia but before they are fully ambulatory. But in a few patients, that gap, that latent error, will be the hole in the system through which they fall. (The post-op period is the highest risk period in small animal anesthesia – perhaps because of the inherent danger of this time period or perhaps because of this common latent error of limited observation post-operatively.)
In many practices, especially with good luck and a low volume of surgeries, this particular organizational practice may not result in a patient death for many years. If and when one finally does occur, it seems to happen out of the blue, but is really a combination of this individual patient’s physiology combined with the latent error in observation, perhaps also combined with other transient or latent circumstances.
If you are interested in learning more about human error and error taxonomy, I would recommend any of the books or articles by James Reason. For some excellent and thoughtful essays on complications and learning in surgery, read Atul Gawande, especially his books Complications, Better, and the Checklist Manifesto.
As for me, I’m doing well. Yesterday I went snowboarding and got to enjoy the remnants of snow and a blue-sky sunny day. An extra wrap of spandex around my waist (a maternity product borrowed from my sister) kept the tube and pouch snug and in place, so no wardrobe malfunctions during my outdoor fun.
Frequently asked question: I have been asked by several people whether I still need to pee “the old fashioned way”after my recent nephrostomy tube placement. Yes! My left kidney drains into thenephrostomy bag (my newfangled bladder), while the right kidney still has a good ureter and drains into my old fashioned bladder. That means that I have to pee twice every time I go to the bathroom since I have two bladders to empty. Downside: bathroom visits take twice as long. Upside: I only have to go to the bathroom half as often.
While I can only speculate about the causes of 
still need to pee “the old fashioned way”after my 