| Nichols Letter, Continued |
Case #10 Tree kangaroo (accession #110974; Pathology case #2002-0298)
Case-related documents are: 1) the medical records (pages 10A1 10A33); 2) the pathology report (pages 10B1 10B2); 3) a biopsy report on the enucleated eye from this animal (page 10C1); 4) an article on tree kangaroo immunology (pages 10D1 10D7)
On January 13, 2001, Spelman placed this tree kangaroo on daily doses of prednisone to treat an acute lameness that she decided was likely related to previously diagnosed vertebral spondylosis. This therapy was initiated without any clinical examination or diagnostic testing; the last physical examination of this animal had been performed approximately 9 months previously (April 2000). Spelman notes in the medical records entry for January 13, 2001 that this animal is "due for annual exam".
On January 23, 2001, BeckyYates ordered that this animal was to remain on daily predisone therapy "until further notice".
On March 1, 2001, Spelman ordered that this tree kangaroo was to be treated with predisone every other day (eod) "until further notice".
On July 3, 2001, this tree kangaroo was given a physical examination. Radiographs revealed worsening of the veterbral spondylosis and the plan noted in medical records was to continue with "pred Rx as before".
On April 4, 2002, this animal was reported to have a "squinty left eye" and the medical entry for that date notes that the tree kangaroo was still on prednisone (almost 16 months after initiation of the therapy). A physical examination performed on April 5, noted that the animal had weight loss with muscle atrophy (i.e. "prominent hips and ribs"). During this tree kangaroo's stay at the vet hospital in April-May, 2002, it was anesthetized 3 times (April 5, April 25, and May 21) for physical exmination due to inflammation of its left eye and/or anemia. The dose of prednisone was decreased and then stopped during this time. The animal was returned to its exhibit on or about May 23.
On June 18, the medical record entry indicates that this animal was observed while on exhibit (but not physically examined) by one of the clinical vets and that it had a history of "facial swelling" which was assessed to be resolving at that time.
On June 21, it is noted that the keeper thinks the animal has a "puffy" eye and is not chewing its food normally. The animal was not physically examined by a veterinarian (or anyone else) but a dental abscess is listed as one of the possible reasons for the puffy eye. However, nothing was done about the animal's condition that day.
On June 23, the animal is again noted to have swelling around the left eye and to not be masticating normally. No physical exam is performed this day, but a dental abscess is again listed as a likely cause of this animal's clinical signs. At this time, the tree kangaroo was started on antibiotic therapy.
On June 24, the animal was found down on the floor of its exhibit and was transferred to the vet hospital, but was still not given a physical exam at this time.
On June 26 (two days after being admitted to the vet hospital and 5 days after the vets were called down to look at the animal for a "puffy" eye), the tree kangaroo was finally given a physical exam and was found to have a facial abscess. A sample of this abscess was taken for culture at this time.
On July 2 (6 days later), it is noted that the culture sample from June 26 had been "misplaced". Therefore, the animal was again anesthetized, examined, and another sample collected for culture. At this time, a lower jaw molar tooth was extracted due to tooth root abscessation.
On July 3, the antibiotic therapy is changed because the culture results indicated that the antibiotic (enrofloxicin aka "Baytril") that this animal had been treated with was ineffective against the bacteria causing the infection.
On July 8, the tree kangaroo was again anesthetized. Three more molar teeth were extracted and the facial abscess/mass was aspirated.
On July 10, Murray notes in the medical records that the animal is to be treated with "lubricant eye drops" until further notice, but she does not state why; this treatment indicates that the animal needed supplemental eye lubrication for some reason.
On July 19, the animal was anesthetized for examination by an ophthamologist and to have the eyelids on its left eye sown shut (i.e. tarsoraphy). The records note that the animal "still does not blink her left eye" and that it was "not clear whether the 5th and 7th cranial nerves are functioning at all".
On July 23, it is noted that the animal's left eye is still markedly swollen and that entire left side of her face was swollen. The decision was made to open the eyelids and then surgically remove the eye.
On July 25, the left eye was surgically removed and submitted for histopathologic evaluation.
On July 31, it was noted that the swelling over the left side of her face had gotten even worse. The tree kangaroo was again anesthetized and had the facial abscess drained.
Between August 1 and the end of September, there were numerous entries in the medical records of this animal describing the continuing problems with facial abscessation and stating that two more teeth were extracted.
On October 1, this animal was taken to a referral veterinary clinic for facial surgery.
On October 10, it is noted that this animal had "pus leaking from face".
On October 11, the tree kangaroo was euthanized.
Question line 1: On January 13, 2001, Spelman ordered that this animal start on prednisone therapy to treat "acute injury + chronic spondylosis". This was done without any physical examination of this animal; the previous physical exam was done almost 9 months previously. Prednisone is an immunosuppressive drug. Do competent veterinarians start treating animals with immunosuppressive drugs without first performing a physical exam of them? Is this malpractice of veterinary medicine?
Question line 2: The medical entry on January 13, 2001 states that this animal is "due for annual exam". However, the animal is not examined until July 3, 2001. Why was there such a delay in performing an examination that was "due"? Do competent veterinarians allow such delays to occur?
Question line 3: Unlike most mammals, tree kangaroos are known to be highly susceptible to Mycobacterium avium -- the organism that causes avian tuberculosis; it has been shown (and published by staff of the Zoo) that this is because this species of tree kangaroo has a poorly-functioning immune system. Therefore, why did Spelman place this tree kangaroo on prednisone --- a drug that is known to suppress the immune system? Wouldn't a tree kangaroo on prednisone therapy be much more likely to become infected with Mycobacterium avium or other organisms? Why was this animal left on treatments with an immunosuppressive drug for well over a year? Could immunosuppression from the prednisone therapy have predisposed the tree kangaroo to bacterial infection leading to tooth root and/or facial abscessation? Would a competent veterinarian leave any animal on prednisone therapy for so long without scheduling several follow-up exams?
Question line 4: One of the known side effects of prolonged prednisone therapy is muscle wasting. Could the fact that this animal was on prednisone for nearly 16 months be the reason that muscle atrophy was noted on April 4, 2002? Why was this animal left on such a therapy for so long? Is this something a competent veterinarian does?
Question line 5: This animal was in the vet hospital from April 4 until sometime at the end of May 2002. Why was it returned to its exhibit in May? Was it clinically normal then? Was its oral cavity closely examined while it was at the hospital?
Question line 6: On June 18 (less than 1 month after being returned to the exhibit), it was noted that this animal had a history of "facial swelling" and that on this day, the swelling appears to be resolving. This is the first reference to facial swelling in the medical record. When was the facial swelling first noticed? Why wasn't this initial observation recorded in the medical records? What was done about the facial swelling when it was first noticed? What was the basis for deciding that the swelling was resolving?
Question line 7: The entry on June 18 implies that facial swelling had been an on-going problem. Three days later (June 21), the veterinary staff again looked at the animal and the assessment was that there was a "swollen eye" possibly due to conjunctivitis, trauma, or a dental abscess, yet no therapy was initiated until 2 days later (June 23) when the antibiotic therapy was started. The following day (June 24), the animal was found down on the floor of its exhibit and was admitted to the vet hospital, however no physical exam was performed until 2 days later (June 26). Why was there a 2-day gap (June 21 until June 23) from the time that a dental abscess was considered as a cause of the facial swelling until the animal was started on antibiotic therapy? Why was there a 2-day gap (June 24 until June 26) from the time the animal was admitted to the vet hospital until it was examined by a vet? If a privately owned animal were admitted to a veterinary hospital by an attending veterinarian and then not examined for 2 days, wouldn't this be considered malpractice of veterinary medicine? Aren't these delays in examining this tree kangaroo a case of neglect and malpractice by the clinical veterinary staff at the Zoo?
Question line 8: Isn't the fact that the bacterial culture taken on July 26 was "misplaced" and thus had to be repeated 6 days later an example of incompetence? The antibiotic therapy was later changed based on the culture results. Therefore, didn't the "misplacement" of the first culture cause at least a 6-day delay in this animal being placed on proper therapy?
Question line 9: On July 8, the tree kangaroo had 3 teeth extracted and also had the facial abscess aspirated. The medical records then note that treatment with "lubricant eye drops" was started on July 10 but there is no indication as to why. Why was this treatment ordered? Was it because the animal's eyelids were paralyzed following the procedures done on July 8? Why wasn't this noted in the medical record?
Question line 10: On July 19, the medical entry states that eyelids of the left eye were sown shut due to severe inflammation and corneal ulceration as a result of the inability of the animal to blink on this side. On July 25, the animal had its left eye surgically removed; the biopsy form submitted with the eye states that: "following a procedure to aspirate a tooth root abscess, Minya experienced cranial nerve damage that rendered Minya unable to close her eyelids or move her eye and she was blind". Thus, as a result of the eyelid paralysis caused by the procedures done on July 8, this kangaroo's eye became so dried-out and inflamed that the eye had to be removed. Isn't this a clear case of malpractice and/or incompetence? As a result, didn't this animal suffer a great deal before having to have its eye removed?
Question line 11: The tree kangaroo was finally euthanized in October after undergoing more than 3 months of having multiple tooth extractions, facial abscess explorations and drainages, removal of one eye, and removal of part of her mandible. Didn't this animal endure much suffering? Shouldn't this animal been euthanized sooner?
Question line 12: Was a "Request for Specimen Euthanasia" form filled out and signed by everyone necessary before the euthanasia -- as is supposed to happen in a case like this? Was this form ever filled out?
Question line 13: Might this entire fiasco have been avoided if the animal had been given prompt veterinary attention in June when it was first requested? Might it have been avoided if the animal was promptly placed on proper antibiotics?
Question line 14: This animal was admitted to the vet hospital on April 5 for a "squinty left eye". It was treated for conjunctivitis and later sent back to the exhibit around May 23. However, less than 4 weeks later swelling around the left eye is reported. What actually was this animal's primary problem on April 5? Was this problem cured at the time the animal was returned to its exhibit? Were the teeth and the rest of the oral cavity closely examined during this animal's hospitalization in April-May, 2002?
Question line 15: This species of tree kangaroo is managed in captivity through a program called the "species survival plan" (aka SSP). The plan for each species has an official clinical veterinarian who provides input on the management of medical issues. The SSP vet for this species is Dr. Mitch Bush who is an employee of the Zoo based at the Conservation and Research Center. Was Dr. Bush consulted about the medical management of this case? Isn't the failure to consult an expert on this species another example of incompetence and/or malfeasance?
Case #11 Micronesian Kingfisher (accession #214083; Pathology case #2002-0253)
Case-related documents are: 1) the medical records for August 2002 that were printed on 29Nov2002 (page11A1); 2) the medical records for August 2002 that were printed on 22Oct2003 (page11B1); 3) the pathology report (pages 11C1 and 11C2)
There are only about 60 individuals of the Guam subspecies of this bird alive in the entire world; all of these exist in captivity. The National Zoo is an active participant in the collaborative plan to try to save this bird from extinction.
The medical records for this bird that I printed out on 29November2002, states that on 14August 2002, the bird was admitted to the vet hospital intensive care unit (ICU) and was "weak/anemic". The bird was found dead the next morning and the information provided along with the carcass by the Department of Animal Health, states that on August 14, 2002, the bird was "nebulized and treated with fluids, later force fed and treated with steroids".
At necropsy, white lesions were seen in the heart and a large mouse pup was found lodged in the esophagus and proventriculus. This mouse pup was so large that the impression at gross necropsy was that the bird (which already had "labored breathing" when presented to the vet hospital) might have "choked to death" on the mouse pup. However, further testing revealed that the kingfisher actually died from inflammation of the heart cause by West Nile virus infection.
Question line 1: This bird died from West Nile virus infection; the heart lesions were so severe that no treatment regimen could have saved this kingfisher. However, this bird was presented to the veterinary staff on August 14 for weakness and labored breathing ---the cause of which was not known at that time. Why was a small (51 g) bird with labored breathing force fed an entire mouse pup? Wouldn't a competent veterinarian have realized that this was a very large and difficult to digest meal for a small bird in respiratory distress? Wouldn't it have made more sense to force feed this bird a gruel-type food or part of a mouse pup?
Question line 2: The medical records that I printed out on 29November2002 have the following entry for 14August2002: "Admitted to ICU; weak/anemic. Keeper (K. Braden) reported (10Aug02) to have observed him with his head caught in a plant otherwise seemed active and alert."
However, when I printed the medical records on 22October3003, this entry for 14August2002 had been drastically altered and now only states: "Rx: Itraconazole (Sporonox) 1 mg PO BID for 30 days."
Therefore, someone changed the medical records at sometime after 29November2002 (which is more than three and one-half months after the bird died). Why have the medical records been altered? Who altered them? Why do they now state something quite different than what they said before and different than what was submitted along with the carcass by the Department of Animal Health at the time of necropsy? Is it ethical to alter medical records more than 3.5 months after a procedure was completed?
Case #12 White-fronted or Geoffrey's marmoset (accession #113220; Pathology case #2002-0263)
Case-related documents are: 1) the medical records (pages 12A1- 12A6); 2) the pathology report (pages 12B1 and 12B2); 3) the euthanasia request form (page 12C1)
This young female marmoset was given an annual physical exam on July 22, 1999 and an abdominal mass was detected through palpation and radiographs. This mass was thought to most likely be a gravid uterus and the plan was to "monitor for delivery".
The next entry in this animal's medical record indicating that it was actually observed by a veterinarian was on August 19, 2002 and it was noted that the marmoset was brought up to the vet hospital because of significant weight loss over the past year. The next entry in the medical records was made on August 26, 2002; it is stated that there is an abdominal mass and that "this mass was noted on July 1999" at the time of its last physical exam. Surgery was performed that day and the mass was removed. On August 28, it is stated that the marmoset "pulled the sutures today" and that she was found with her gastrointestinal tract (GIT) "hanging out". The marmoset was rushed to surgery and the surgery notes state: "There was a large 1 cm tear in the large bowel, small pinpoint defects in the cecum, and the entire small intestine was ripped off the mesentery." During surgery, "the cecal and large intestinal defects were closed" and "the devitalized small intestine was resected". In the assessment notes, it is stated that: "prognosis is poor due to large section of SI removed today". The entries made on August 30, August 31, and September 1 discuss that the marmoset appeared depressed but "surprisingly active".
The next medical entry was made on September 4 and this notes that the marmoset "appeared painful and her bowel was distended". The animal was anesthetized and an abdominal tap revealed cloudy red fluid. Exploratory surgery revealed a "greatly distended" large bowel and that there was "leakage at the initial surgery site" of the remnant small intestine. The marmoset was then euthanized.
Necropsy of this animal revealed it had fibrinous peritonitis with multiple intra-abdominal adhesions. The remaining small intestine measured 15 cm in length and the colon was 31 cm long.
Question line 1: This marmoset was given an annual physical exam in July 1999 and was not examined again until August 2002 --- more than 3 years later. Do competent veterinarians allow more than 3 years to pass between "annual" physical exams?
Question line 2: An abdominal mass was found at the exam in July 1999 and this was thought to most likely be a gravid uterus. The plan was to "monitor for delivery". When the marmoset did not give birth after a normal gestation period, why was there no follow-up exam? Isn't the failure to perform a timely follow-up examination an indication of incompetence?
Question line 3: Primates are notorious for picking at and pulling out sutures. What precautions were taken to try to prevent this marmoset from pulling out its sutures? How closely and how often was this animal monitored in the days post-surgically to ensure that it was not picking at the sutures?
Question line 4: After this animal pulled out its sutures and it was discovered that "the entire small intestine was ripped off the mesentery", the devitalized small intestine was removed. How much of the small intestine was this? What is the prognosis for any animal that has this much of the small intestine removed? Why was this surgery even attempted? Shouldn't this marmoset have been euthanized rather than have the majority of its small intestine removed? Didn't this animal needlessly suffer for seven days (August 28 September 4) from the time the intestine was removed until it was euthanized?
Question line 5: Given that this animal had such a major surgery and that the medical records on the day of surgery indicate a poor prognosis, shouldn't this marmoset been monitored very closely in the days following surgery? Was it? Why are there no entries in the medical record for September 2 or September 3? What was this animal's condition during these two days?
Case #13 Giraffe (accession #106318; Pathology case #2002-0260)
Case-related documents are: 1) the medical records for 2002 (pages 13A1 13A10);
2) the pathology report (pages 13B1 13B2)
This old female giraffe was a mate to the one that died in February 2002 (case #7 above).
On 24January2002, this giraffe was started on injections of "Triple crown chondroprotectant" to treat a lameness problem. The medical records on this date indicate that this was therapy was the "Anakis protocol" and that this protocol calls for an injection of the "chondroprotectant" once every 4 days for 6 treatments.
On 5February2002, the giraffe was given the 4th injection of the "Anakis protocol".
On 20February2002, the giraffe was given the 5th injection of the "Anakis protocol".
The next medical records entry is on 3April2002 and it indicates that "green material" that "resembles the green fluid material seen on Ryma's floor previously" was found in this giraffe's enclosure (Ryma is the male giraffe that died in February -- case #7). It is also speculated that this "abnormal regurgitation" may "correlate with adequan injection".
On 28April2002, the giraffe was thought to have worse lameness/locomotor problems and there is a reference in the records to a telephone consultation with Dr. Anakis.
On 11June2002, the giraffe was started on oral treatments with "ibuprofen 1500 mg SID for 30 days".
There are no further statements in the medical records about ibuprofen until 29August2002 when it is noted that this giraffe is not eating well and that "keepers feel the ibuprofen may be putting her off."' The stated plan that day is to "decrease ibuprofen to 1500 mg PO SID."
On 30August2002, there was concern that the decreased appetite may be caused by "gastritis from ibuprofen".
On 31August2002, it was noted that this giraffe's "abdomen is round and bloated" and that the animal "appears painful and/or to have colic". It was also noted that possible causes for this animal's problems include "dental disease" and "bloat". The records then state that Dr. Scott Citino and Dr. Stephanie James were consulted for "possible dx/tx measures". The therapy given that day included "soap po (for frothy bloat)". A later entry for that day notes that "Dr. Anikis" was consulted by telephone about the causes of bloat in this giraffe and that he "advised to give 20-30 ccs of detergent orally" in order "to relieve frothy bloat". The final entry on the medical records that day states that there was a "phone consult with Dr. Mitch Bush" about "whether to pursue a standing sedation, full sedation, or attempt treatment". It is noted that Dr. Bush suggests contacting Dr. Citino if the vets at the Zoo want to "pursue standing sedation or treatment".
On 1September2002, the giraffe's main problem was stated to be "ruminal tympany" and that the animal "hasn't laid down in 2 days". The assessment was that the "abdomen looks less rounded than yesterday in a.m. and she doesn't seem to be in much pain and/or colicky". The giraffe was again treated with "soap po (for frothy bloat)".
On 2September2002, the medical records note that around 7:30 am "during discussion of clinical options", the giraffe fell down and a "large amount of green fluid, likely ruminal contents (50-75 gallons?) came out from mouth". The giraffe died within a few minutes.
The necropsy revealed that this giraffe had a milder case of "frothy bloat" than what was present in the male giraffe that died 7 months before (see case #7). However, this animal had marked serous atrophy of fat indicating that it had recently "burned up" all of its remaining fat reserves of energy. The cause of death for this animal was attributed to nutritional and digestive problems associated with severe dental disease and abnormal rumination that ultimately manifested as serous atrophy of fat.
Question line 1: The medical records clearly indicate that this giraffe was being treated for lameness problems with a therapy protocol developed by Dr. Anakis. Dr. Anakis was also telephoned on 31August2002 and consulted about what might cause frothy bloat in this giraffe and how to treat this condition in this animal. Who is Dr. Anakis? What training and other qualifications does he have to treat giraffes and other zoo animals? How many giraffes had he previously treated for lameness or frothy bloat? How many giraffes had he previously treated for any disease? How many zoo animals had he previously treated? How many ruminant animals had he previously treated for lameness with this protocol and were these treatments successful?
Question line 2: As previously noted for Case #7 above, Dr. Mitch Bush is a world-recognized expert on anesthesia and veterinary medicine of giraffes; he has authored chapters on these subjects in various editions of the text Zoo & Wild Animal Medicine. The medical records indicate that Dr. Bush was telephoned late in the day on 31August2002 (less than 2 days before the giraffe died) and asked about' "whether to pursue a standing sedation, full sedation, or attempt treatment". Was Dr. Bush invited to come and actually look at or work on this giraffe or was he just asked to make a "telephone diagnosis"? Was Dr. Bush ever consulted prior to 31August2002 about the medical problems of this giraffe? If not, why not? Wouldn't it make sense to consult a readily-available expert on giraffe medicine rather than Dr. Anakis?
Question line 3: The medical records on the male giraffe that died in February 2002 (see Case #7 above) clearly indicate that this animal had been treated for chronic lameness with the same drugs used in "the Anakis protocol" and that there were concerns the "abnormal regurgitation" seen in that giraffe were associated with treatment with these drugs. Therefore, why was this female treated with the same drugs? Why wasn't there more concern by the clinical veterinarians when the medical records entry on 3April2002 indicates that "green material" that "resembles the green fluid material" seen with the male giraffe was found in this giraffe's enclosure (especially when these records state that this abnormal regurgitation may "correlate with adequan injection")? Why was this giraffe left on this therapy?
Question line 4: The medical records indicate that on 11June2002, the giraffe was started on oral treatments with "ibuprofen 1500 mg SID for 30 days". Treatment with oral ibuprofen apparently continued through at least 29August2002 when the records state that this giraffe is not eating well and that "keepers feel the ibuprofen may be putting her off." The stated plan that day is to "decrease ibuprofen to 1500 mg PO SID." Was this giraffe given oral ibuprofen the entire time from 11June 29August2002? When was the dose of this drug increased from the initial 1500 mg? Why was this female giraffe placed on oral ibuprofen therapy when the records from the male giraffe that died in February 2002 (Case #7 above) clearly suggest there may have been an association between oral ibuprofen therapy and the development of frothy bloat?
Question line 5: The medical records entry on 24January2002 states that the "Anakis protocol"requires an injection of the "chondroprotectant" once every 4 days for 6 treatments. On 5February2002, the giraffe was given the 4th injection of the chondroprotectant and the 5th injection was given on 20February2002. Why was there a 15-day gap between the 4th and 5th injections? There is no indication in the medical records that the 6th injection was ever given was it? How can one evaluate whether a particular treatment protocol is effective if the protocol is not followed? Is this how competent veterinarians practice medicine?
Question line 6: We pathologists felt that dental disease was a very significant factor that contributed to the deaths of both of the giraffes. But Dr. Murray initially refused to acknowledge that the dental problems in either of these giraffes were severe or that they were contributory to the giraffes' deaths. Why did Murray refuse to believe the findings of two board-certified veterinary pathologists with more than 50 years combined experience in zoo animal pathology? Dr. Charles Williams, a board-certified veterinary dentist, examined the skulls and dental radiographs from both of the giraffes; he felt the dental disease present was even more severe than we pathologists had thought and that it was certainly contributory to the giraffes' digestive problems. Does Murray now believe that the dental problems were significant?
Question line 7: After this female giraffe died, Spelman ordered Belinda Reser, the curator in charge of the Elephant House (where the giraffe was housed), re-assigned. Why? Did Spelman think that Reser was somehow at fault for the giraffe's death? If so, how exactly was Reser at fault?
Question line 8: The medical records clearly indicate that there was no follow-up by the veterinary staff when "green fluid material" similar to that seen before male giraffe died was found in the enclosure of this female giraffe on 3April2002. The records also indicate that beginning on 11June2002, this giraffe was placed on daily oral medication with ibuprofen --- a treatment that was associated with the development of frothy bloat in the male giraffe. Doesn't it appear that, if anyone should be blamed for the death of this giraffe, it should be the veterinary staff? Therefore, shouldn't Spelman have reprimanded the veterinary staff instead of the curator?
Case #14 African lion (accession #108413; Pathology case #2002-0297)
Case-related documents are: 1) the medical records for October 2002 which were printed out on 21October2002 (pages 14A1 and 14A2); 2) the medical records for October 2002 which were printed out on 26September2003 (pages 14B1 14B3); 3) the medical records for 1995 through September 2002 which were printed out on 22October2002 (pages 14C1 14C14); 4) the pathology report (pages 14D1 14D4); 5) the anesthesia records report for this animal (pages 14E1 14E16); 6) a table I made summarizing the anesthetic procedures performed on this lion (page 14F1)
A lion died overnight on October 10, 2002 due to severe pulmonary congestion and edema. This animal had been anesthetized and examined by Spelman and Murray on the morning of October 10. After a complete post mortem examination, the cause of the lion's death was determined to be acute pulmonary edema, which was attributed to complications of the anesthetic procedures done on October 10.
The medical records show that this lion had been anesthetized for physical examinations on at least 8 occasions prior to October 10, 2002 (i.e. 31May1995, 31January1997, 6January1998, 13January1999, 13February1999, 29February2000, 8March2001, 5February2002). On each occasion, a combination of the drugs xylazine and ketamine were used to induce anesthesia and the drug yohimbine was used to reverse the effects of the anesthetics. The dosages of these drugs and the routes of administration (intramuscular [IM] or intravascular [IV]) varied somewhat from one anesthetic event to another but the same basic anesthetic protocol was used each time. On some occasions the drug midazolam was also included to help control seizures that ketamine can induce. These same drugs were used on this lion on October 10, 2002 --- however the amounts of xylazine and ketamine that were administered and the procedures used to administer them differed markedly from those used previously.
My review of the medical records (including the "anesthesia records report") and my interviews with the involved veterinarians, animal keepers, and curator revealed the following information about what happened on October 10, 2002:
At 8:49 am on October 10, Murray and Spelman allowed an animal keeper (Mindy Babitz) to inject 500 mg of xylazine into the lion using a hand-held syringe. Although this keeper was inexperienced at doing this, Murray and Spelman stood where the lion could not see them (in an attempt to avoid upsetting the animal) and where they could not witness the keeper administering the injection. Although the syringe was empty after the injection and the keeper felt that all of the drug had been injected into the lion, the animal did not become as sedated as Murray and Spelman expected, and the entry in the medical record states "we believe he may have gotten some Xylazine but perhaps not all". Therefore, at 9:15 am, the lion was administered another 40 mg of xylazine plus 550 mg of ketamine this time using a dart gun. Seventeen minutes later (9:32 am), when the lion still was not as anesthetized as Murray and Spelman wanted, it was given another 300 mg of xylazine and 250 mg of ketamine by dart gun. At 9:44 am, it was given another 100 mg of ketamine IV and another 100 mg of ketamine IM. Four minutes later, it was noted to have a seizure so it was given midazolam IV, following by another dose IV two minutes later. The lion was then placed on gas anesthesia (isoflourane) and taken by van up to the veterinary hospital. It is noted in the medical records that the endotracheal (ET) "tube may have been in too far, so it was moved back a little". It is also noted that animal's heart rate at one point was "over 100 bpm for a while" and that "we are unsure of the cause" but "one hypothesis is that it was due to trach tube being in too far". The medical records also indicate that the lion's body temperature at 9:58 am was 105.7 F, twenty-two minutes later the temperature was down to 103.8 F, and twenty-one minutes after that it was down to 102.3 F. It is also stated that "an IV catheter was placed in R medial saphenous vein at 10:37 but it came out ten minutes later" and that "another catheter was not placed". Under the sections describing the medications that were administered during this examination, the records state the lion was given lactated ringers solution (LRS) however only "a small amount IV, but because the catheter only stayed in for 10 minutes, fluids were given SQ". The lion was returned to the Lion/Tiger House around 12:15 pm and given yohimbine to reverse the anesthesia. The first signs of recovery were noted nine minutes later and the animal was "left with keepers to monitor in cage". The lion was found dead in its cage the next morning.
Question line 1: A review of the medical records and the anesthetic records reveals that, in the 8 anesthetic procedures this lion had prior to the October 10, 2002, the animal had usually been given a total xylazine dose of 400 to 450 mg and a total ketamine dose of 450 to 510 mg. Prior to October 10, 2002, the greatest cumulative xylazine dose this animal had ever been given during a single anesthetic procedure was 550 mg (on February 5, 2002) and the greatest cumulative ketamine dose was 550 mg (also on February 5, 2002). On October 10, 2002, however, the initial dose of xylazine that was administered was 500 mg and the initial dose of ketamine was 550 mg. These were followed by two more doses of xylazine and three more doses of ketamine, so that the total dose of xylazine given to this lion on October 10, 2002 was 840 mg and the total dose of ketamine was 1000 mg. Why did Spelman and Murray begin with such high doses of the two drugs? Isn't this unusual since this lion had successfully been anesthestized in the past at lower doses of each drug? Weren't either of them concerned when the cumulative drug dose so far exceeded what this animal had received in the past? Can it be truthfully stated that was nothing unusual about this particular anesthesia?
Question line 2: Looking at the anesthetic record data on the 8 previous anesthetic events, the heart rates recorded on this animal were usually between 45 and 60 beats per minute (bpm). The greatest heart rate noted previously was 90 bpm (on May 31, 1995). Therefore, isn't it unusual for this lion to have a heart rate "over 100 bpm for a while"?
How long is "a while"? Can it be truthfully stated that was nothing unusual about this particular anesthesia?
Question line 3: Would a competent veterinarian allow an endotracheal tube to be placed too far down the trachea? Wouldn't this pose a threat of insufficient aeration of one side of the lungs? Could this be responsible for the lion's high heart rate as hypothesized in the medical records? Had this ever happened during anesthesia of this lion in the past? Can it be truthfully stated that was nothing unusual about this particular anesthesia?
Question line 4: Looking at the anesthetic record data on the 8 previous events, this lion's body temperature while under anesthesia was usually between 100.2 and 101.8 F. The highest previous body temperature recording was 102.9 F (on March 8, 2001). Therefore, isn't it unusual that on October 10, 2002, the initial body temperature recorded on this lion was 105.7 F and that 22 minutes later the temperature was still 103.8 F and that 21 minutes after that it was still 102.3 F (which was still the fourth highest body temperature ever recorded for this animal)? A temperature of 105.7 F is quite high for a cat; didn't this concern Murray or Spelman? The initial body temperature recording of 105.7 F was made at 9:58 am --- 1 hour and 9 minutes after this lion received its first dose of xylazine. Therefore, it is not known how high this animal's body temperature may have gotten during the 69 minutes between initial drug administration and the first measurement of body temperature, nor is it known how long the temperature was at 105.7; didn't this concern Murray or Spelman? Can it be truthfully stated that was nothing unusual about this particular anesthesia?
Question line 5: Is it typical to have an IV catheter "come out" from this lion 10 minutes after it was placed into a vein and to then have to give fluids subcutaneously instead of IV? Can it be truthfully stated that was nothing unusual about this particular anesthesia?
Question line 6: Do animal keepers typically administer anesthetic drugs to animals at the National Zoo? What training and qualifications to administer anesthetic drugs did the keeper in this case have? How many times had she done this in the past? Can it be truthfully stated that was nothing unusual about this particular anesthesia?
Question line 7: Murray was interviewed by the Washington Post about the death of this lion. In the published interview, Murray indicated that there was nothing unusual about the anesthetic procedure performed on this animal on October 10, 2002. Is this truthful or is it a lie? In the information about this lion that was submitted to the Department of Pathology by Murray at the time of necropsy, she wrote that the anesthesia was "relatively uneventful". Is this truthful?
Question line 8: Is it legal or ethical for a veterinarian to allow a lay person to administer anesthetic drugs to an animal, especially when this is done in such a manner that the veterinarian cannot witness the procedure? If a veterinarian in private practice allowed a lay people to do this, wouldn't that be considered malpractice?
Question line 9: Isn't it possible that all of the initial dose of xylazine (which was administered by the animal keeper) was in fact injected into this lion but that all or part of it was injected subcutaneously and/or into fat instead of IM? Could this explain why the lion did not respond as quickly as expected? Does anyone know exactly how much xylazine was given to the lion? Didn't Murray and Spelman lose control of the anesthetic procedure at the moment they handed the syringe of xylazine to the animal keeper? Isn't this clearly a case of malpractice? Wouldn't competent zoo veterinarians have called off the procedure that day when the lion did not respond as expected to the anesthetics --rather than give the animal multiple injections until it finally was anesthetized after receiving cumulative doses of the anesthetics which far exceeded any that this animal had previously received?
Question line 10: The highest cumulative dose of xylazine and the highest cumulative dose of ketamine ever given to this lion during a single anesthetic procedure prior to 10October2002 was 550 mg of each drug; this was done on 5February2002. The medical records contain information about the anesthesia of this lion on that day but this information is missing from the anesthesia records for this animal --- why? The medical records for 5February2002 indicate that the lion was initially injected with 450 mg of xylazine IM "via hand syringe by keeper". However, when the lion did not respond as expected, it was given another 50 mg of xylazine IM as well as 400 mg of ketamine IM. When the animal still did not become as anesthetized as expected, it was given another 100 mg of ketamine IM, followed by another 50 mg of ketamine IV and another 50 mg of xylazine IV. Doesn't this again suggest that the initial dose of xylazine injected into this lion did not all go IM? Isn't it interesting that the only two times (i.e. 5 Feb2002 and 10Oct2002) that a keeper was in charge of giving the initial dose of xylazine resulted in this lion having to be given multiple supplemental doses of xylazine and ketamine, causing this animal to have the two highest cumulative doses of these drugs? Therefore, wouldn't competent veterinarians realize that having animal keepers administer anesthetic drugs to zoo animals might jeopardize the health of these animals?
Question line 11: Why did neither Murray nor Spelman go back and look at this lion after the animal had been returned to its exhibit? It was reported that an animal keeper called the vet hospital sometime between 1 and 2 pm that day to express concerns about how the lion was acting but that Murray told the keeper that lion was OK. Wouldn't a competent veterinarian have gone down to look at the lion rather than make an assessment of its condition over the telephone? Shouldn't Murray have been especially concerned about this lion's post-anesthestic behavior that day? The animal keeper (Tracey Barnes) on the late shift that day was so concerned about the appearance of the lion at 6:30 pm, that she called the vet hospital and left a message on the answering machine expressing her concerns. However, Murray and the other clinical vets had already gone home for the evening and thus did not get the message until the next morning (after the animal was already dead). Shouldn't Murray and/or Spelman have gone back down to observe the lion before leaving for the day?
Question line 12: On October 21, 2002, I printed out the lion's medical record entry for October 2002 and the only entry in the record was for 10October2002 (the day of the anesthesia). However, I misplaced that printout. Since I needed this information while preparing this report, on September 26, 2003 I again printed out the medical record entry for October 2002. Afterward, I found the printout from October 21, 2002. Comparing the two printouts, I noticed that someone altered the medical records at sometime after October 21, 2002. Many of the alterations are changes in wording that do not significantly change the record. However, the following pieces of important information were present in the October 21, 2002 printout but are missing from the September 26, 2003 printout of the medical records:
a) the fact that a keeper administered the initial dose of xylazine
b) the fact that the endotracheal tube was thought to have been too far down the trachea and was moved back
c) the hypothesis that the high heart rate was associated with the erroneous placement of the endotracheal tube
d) the fact that an IV catheter was put in a vein but came out in 10 minutes
e) the fact that because the IV catheter came out, fluids had to be given subcutaneously
Other important differences between the two printouts include:
a) In referring to the initial xylazine injection the statement "We believe he may have gotten some Xylazine but perhaps not all", which appears in the October 21 printout of the medical records has been replaced by "It is unlikely that he received the entire dose" in the later "version" of the medical records. Also, the statement "This is consistent with incomplete initial injection" was added sometime after October 21, 2002.
b) Both records say that the lion had a seizure at 9:48 am but in the latest version of the printout, this is now a "mild" seizure
c) The statement "We did not witness any subsequent seizures in this animal for the rest of the anesthetic period" which appears in the October 21 printout has been replaced by "Lion was stable under anesthesia" in the September 26 version.
d) In reference to the heart rate, the following appears in the October 21 printout: "it rose and was over 100 bpm for a while. Even counting with a stethoscope showed it was indeed this high. We are unsure of the cause." In the September 26 printout, this has been replaced with: "but was then later elevated to 110 bpm for a short period, and then returned to approximately 70 bpm."
e) The September 26, 2003 version of the medical records has an entry for 11October2002; there was no entry for this date in the earlier version. In this entry there is a statement that "recovery yesterday was uneventful".
Why were the medical records altered? Who altered them? Isn't it obvious that the intent of the alterations listed above was to remove any statements that made it appear that there were any problems with or anything unusual about this anesthetic event?
Question line 13: Is it ethical to alter medical records more than 11 days after a procedure was completed? Is this legal? Isn't this another example of alteration of federal documents to cover-up malpractice?
Case #15 Bobcat (accession #103175; Pathology case #2002-0322)
Case-related documents are: 1) the medical records printout from 26November2002 (pages 15A1 15A14); 2) the medical records for 2001-2002 which were printed out on 9October2003 (pages 15B1-15B6); 3) the pathology report (pages 15C1 15C3);
4) a clinical laboratory summary report for this animal (pages 15D1 and 15D2)
This aged female bobcat was euthanized on November 21,2002. A review of this animal's medical records that were printed out on November 26, 2002 reveals that this bobcat had annual physical examinations on 7June1995, 12February1997, 15January1998, 14January1999, 13April2000, 30March2001, and 22Februrary2002. As part of these routine physical exams whole body radiographs were taken on 6 occasions (all exams but the one on 7June1995) and were assessed to be within normal limits (WNL) each time. During each of the last three exams (2000, 2001, 2002) the toenails were noted to be excessively long and were trimmed. Results of the exam on 22Februrary2002 revealed that the bobcat was thin and dehydrated. This animal's blood urea nitrogen (BUN) and serum creatinine were both increased, which indicated that the animal had compromised kidney function. The medical record entry on 24February2002 2002 states "consider re-check on 3-6months". On June 21, the bobcat was started on daily aspirin therapy and the reason for this is stated as "today this bobcat was reported as not active and not eating great. Previous Xray show severe generalized DJD". The next entry in the medical records was made on November 13 and refers to the upcoming winter and "quality of life" for this aged animal. On November 20, the medical entry states that: "beaver valley keeper staff have elected for euthanasia due to poor quality of life and poor prognosis for survival through the winter". On November 21, the bobcat was euthanized and a blood sample was collected from the animal after it was dead.
The necropsy revealed that this bobcat did have renal disease. However the renal disease was not so advanced as to qualify as "end-stage kidneys". In addition, the serum creatinine level in the post mortem blood sample was actually significantly less than it was in the blood sample from February --- suggesting that the renal function might actually have been better in November than it was in February. The necropsy also revealed that the bobcat did not have generalized arthritis or degenerative joint disease (DJD); the only degenerative joint changes found were in one shoulder and these were mild. However, two toenails on the left front foot and two toenails on the right front foot had become so overgrown that they had grown into the pads of the feet' --- causing these pads to become abscessed. The bobcat's inactivity and reluctance to move were not because of arthritis and renal failure but were due to the appalling condition of its front feet.
Question line 1: What did the clinical veterinarians base their diagnosis of generalized arthritis on? This animal had whole body radiographs taken numerous times and the medical records entries had always stated these were "WNL". Therefore, why was this animal started on aspirin therapy on June 21, 2002 for "severe generalized DJD"? Isn't this a case of malpractice of veterinary medicine?
Question line 2: After the blood results from the February 2002 exam indicated this animal had compromised renal function, the stated plan was "consider re-check" of this animal in "3-6 months". But this was never done --- why not?
Question line 3: Why was the decision made to euthanize this animal without at least giving it another physical exam first? Is this sound practice of veterinary medicine? What are the ethics and/or competence of a veterinarian who diagnoses renal failure and severe arthritis without examining an animal and then justifies euthanasia of that animal based on these diagnoses?
Question line 4: During its last three physical exams, this bobcat's toenails needed to be trimmed because they were overgrown. Therefore, shouldn't toenail overgrowth have been considered as a possible cause of this animal's reluctance to move?
Question line 5: Couldn't the overgrown toenails have been corrected or maybe prevented if the bobcat had been examined more closely by the keeper and veterinary staff? If the bobcat had been given a proper medical examination for its "lameness", couldn't the toenails have been trimmed to relieve its suffering instead of forcing it to try to walk on abscessed feet for weeks?
Question line 6: The medical record entry on November 20, 2002 states that the "beaver valley keeper staff have elected for euthanasia". Why was this decision left up to the keeper staff? Shouldn't the curator and veterinary staff be involved in this decision? What are the ethics and competence of a veterinarian who agrees to euthanize an animal because the keeper staff thinks it is time to do so (and without giving the animal a physuical examination first)? Was it actually necessary to euthanize this animal on Novemeber 21, 2002? What is the Zoo policy/protocol for deciding elective euthanasia in a chronically ill animal? Was this policy followed in this case?
Question line 7: Was a "Request for Specimen Euthanasia" form initiated prior to the euthanasia of this animal? Was this form ever filled out?
Question line 8: The information submitted by Dr. Sharon Deem along with the carcass to the Department of Pathology states that the bobcat had a "prolonged, difficult recovery" following the anesthesia in February. Because of this, "the veterinary staff, curators, and keepers decided ... that further anesthetic procedures would not be pursued". Dr. Deem did not start working at the Zoo until August 2002 and the medical records at the time the bobcat was euthanized said nothing about a prolonged recovery from anesthesia in February; therefore, how could Dr. Deem know about what happened to this bobcat in February? Was Deem actually qualified to comment on what happened to this animal nearly 6 months before she started working at the Zoo? Why are curators and keepers deciding whether an animal should be anesthetized isn't that a medical decision that should be made by people trained in medicine?
Question line 9: Veterinarians in private practice frequently have to anesthetize old cats in renal failure; wouldn't a competent veterinarian know anesthetic protocols that can be safely used in an old cat with renal failure?
Question line 10: On November 26, 2002 (5 days after the bobcat was euthanized), I printed out the bobcat's medical records. On October 9, 2003, I again printed out the medical record entries for the years 2001--2002. Comparing the two printouts, I noticed that someone altered the medical records at sometime after November 26, 2002. The following entries appear in the medical records printout in October 2003, now but were NOT in the November 2002 printout:
Hx: Keepers report prolonged and difficult wake-up. Animal is depressed today and does not want to eat.
A: Bloodwork results show elevated kidney enzymes. R/O progresssive renal disease
P: Tempt animal to eat, consider modifying diet. Administer antibiotics for root canal procedure.
Hx: Keepers report this animal is still not eating well. Likely due to the combination of anesthesia and renal failure. Discussed many options including EOD fluid therapy which would only be possible with sedation considered not practical and too stressful. Keepers would like to attempt to keep her comfortable and eating as long as possible with medications and dietary modifications. When her quality of life is no longer acceptable, keepers to contact vets. Advised that this could happen quickly (i.e. days, or perhaps many months).
In the "Results" of the analysis of the blood sample collected 2 days previously, the fact that at hematocrit (HCT) of 29.5 is normal (norm) has been changed to "low norm"
Hx: Keepers will switch to more Dallas diet in an attempt to get animal to eat. Keepers will also try chicks and rat pups to try to get some more weight on her.
Hx: Valley keepers contacted DAH today to request euthanasia. Keepers report that she has decreased appetite, she appears hunched over at times, and has demonstrated some ataxia with trembling of hind legs. Keepers feel that her quality of life has declined dramatically. Discussed briefly with curator and scheduled euthanasia for tomorrow.
Some of the results from the analysis of the blood sample collected post mortem have been added
Why were the medical records altered? When were they altered? Who altered them? Doesn't it appear that the added information is there to try to justify the failure of the veterinary staff to properly exam this bobcat before euthanizing it?
Question line 9: Is it ethical to alter medical records weeks to more than 9 months (in the case of the alterations made for the February exam) after a procedure was completed? Is this legal? Isn't this another example of alteration of federal documents to cover-up malpractice?
Case #16 Red pandas (accession #113194 and 111967; Pathology cases #2003-0010 and 2003-0011)
Case-related documents are: 1) the pathology report for case #2003-0010 (pages 16A1- 16A3); 2) the pathology report for case #2003-0011 (pages 16B1 and 16B2); 3) part of a chapter on "vermin control" written by Spelman (pages 16C1 and 16C2)
Two red pandas were found dead in their exhibit on January 11, 2003. The previous afternoon, aluminum phosphide had been put into several rat burrows that were in the exhibit. This was done in an attempt to poison the rats, which had become a significant problem zoo-wide. But instead of removing the red pandas from the exhibit while this was being done, the pandas were left in the exhibit. The necropsy findings revealed that they died from aluminum phosphide toxicity. This was a careless and easily avoidable mistake that caused Spelman to order major staff changes: the head of the Animal Programs department (Ben Beck) and the head animal curator (John Seidensticker) were re-assigned so that neither of them any longer had anything to do with day-to-day animal care decisions. In addition, the person in charge of the Zoo's pest control program, Mr. Garrick Smith (who was also the head of the safety office) was coerced to retire. Until the summer of 2000, the Zoo's pest control program was always managed by a veterinarian in the Department of Animal Health. Dr. Mitch Bush did this for many years; after he moved out to the Conservation and Research Center (CRC), Dr. Cambre was in charge of it. After Dr. Cambre left, Spelman was in charge of pest control. In fact, Spelman is supposed to be such an expert on this topic that she wrote a chapter on "vermin control" in zoos in the fourth edition of the book "Zoo & Wild Animal Medicine". In the second paragraph of this chapter, Spelman states that "In a zoo or wildlife park, the veterinary staff should oversee any method involving chemical agents or animal handling." However, one Spelman's first actions after becoming the director of the Zoo was to put Garrick Smith, in charge of the pest control program. Mr. Smith had no training or other qualifications to head this program.
Question line 1: Why did Spelman decide to put someone with no veterinary medical knowledge in charge of pest control? Isn't this in direct conflict with what Spelman wrote in her chapter on vermin control? Isn't this an example of hypocrisy?
Question line 2: By appointing an untrained and unqualified person to be in charge of pest control, doesn't this mean that Spelman must also take responsibility for the deaths of the red pandas?
Question 3: Since the panda deaths resulted in severe reprimands for the other Zoo staff members perceived to be responsible, shouldn't the deaths of these red pandas have also resulted in severe reprimands for Spelman? Isn't the lack of such reprimands for Spelman an example of hypocrisy?
Case #17 Bactrian Camel (accession #107662)
Case-related documents are: 1) the medical records (pages 17A1 17A17); 2) clinical pathology log for all blood samples from this camel submitted for analyses (page 17B1)
This is an old female camel with a long clinical history of lameness with abnormal locomotion and periodic bouts where she either refuses to stand or has great difficulty in standing up. In addition, her male exhibit-mate is repeatedly aggressive towards her. This animal's condition has generated multiple complaints from the Zoo's visitors and numerous discussions about this camel's "quality of life" among the veterinary staff, animal keepers, and curators. In fact, when this animal became markedly worse at the end of August 2002, a decision was made to euthanize this animal. On August 30, I was told by Suzan Murray that the euthanasia of this animal was scheduled for Wednesday, September 4, 2002. The reason that this was to be done on Wednesday was so that the veterinary clinical resident, Carlos Sanchez, could participate and gain experience in the necropsy (the clinical residents rotate through the Department of Pathology on Wednesdays). However, a giraffe died on Monday, September 2, 2002 (see case #13 above) and a grey seal died overnight on September 2-3. Murray then informed me that the camel euthanasia would be postponed indefinitely because it "would look bad" to the media/public for the Zoo to have three large animals die in three consecutive days.
Of course, several more "high-profile" animals died over the subsequent months (see cases 14, 15, and 16) and then the Zoo came under intense media scrutiny.
The camel is still alive as of November this year --- more than 14 months after it was scheduled to be euthanized.
Question line 1: What is the "quality of life" for this camel? Should it have been euthanized 14 months ago? If so, why is it still alive? Should the view that "the media" might potentially take be a factor in delaying the euthanasia of an animal? Shouldn't the welfare of the animal be the top priority? What are the ethics of veterinarians who prioritize "public relations" above animal welfare?
Question line 2: If this camel should not have been euthanized 14 months ago, why was it scheduled for euthanasia on September 4, 2002? What is the competence level of veterinarians who cannot decide when it is the appropriate time to perform euthanasia?
Question line 3: The medical records and the records from the clinical pathology laboratory indicate that this animal has not been given a physical examination or had a blood sample collected since March 9, 2000. Why hasn't this camel had a physical exam in over 3 years? Should the decision to euthanize this animal be made without a physical exam?
Question line 4: What is the Zoo policy/protocol for deciding elective euthanasia in a chronically ill animal? Was it followed prior to the decision that this camel should be euthanized on September 4, 2002?
Case #18 Lion-tailed macaque (accession #107365)
Case-related documents are: 1) the medical records (pages 18A1 18A3)
This macaque was anesthetized on March 27, 2003 for physical examination and exploratory surgery of previous vasectomy sites. At the end of the day, this animal was returned to its off-exhibit housing in the "Propagation Building". However, the keeper on duty that afternoon contacted me (as co-chairman of the IACUC) with a concern over the animal's welfare because the keeper felt the macaque was still very groggy from the morning's anesthesia. This keeper was especially concerned about this animal because of the circumstances surrounding the death of the lion the previous October (see case # 14 above). I told the keeper to first contact the curator in charge of that area and then the veterinary staff to express these concerns. I said that if this did not produce satisfactory results, then she should call me back. After I had not been called back in approximately 1.5 hours, I called the keeper and found out that both the curator and Murray had come down to see the macaque and the keeper felt things were OK. However, the keeper also told me that she was told the reason the macaque was still groggy was because it had to be given a supplemental injection of anesthetic. I then looked at the medical records on this animal and saw there was no entry indicating this animal was given any injectable anesthetics other than the initial injection of 100mg of ketamine. Five days later, I checked the medical again and saw that they still said nothing about a supplemental dose of anesthetic. So I then contacted Murray to try to find out more about what happened. She informed me that after the macaque had recovered from anesthesia, it was able to unlatch the door to the cage it was in at the vet hospital and Murray had to give it a supplemental dose of the anesthetic ketamine to prevent the animal from escaping from the cage; this is why the macaque was still groggy when returned to the Propagation Building.
Question line 1: Why don't the medical records indicate that this animal was given another dose of ketamine? Was this an attempt to cover-up the fact that the animal was in the process of escaping its cage at the vet hospital?
Question line 2: Isn't ketamine a controlled drug? Aren't veterinarians required to keep track of their use of controlled drugs? If a veterinarian in private practice were to fail to record use of ketamine, wouldn't that veterinarian be subject to sanction by the Drug Enforcement Agency (DEA) and/or state licensure agency?
Cases from 1998:
Case #19 Giraffe (accession #104081; Pathology #1998-0128)
Case-related documents are: 1) the medical records for 1997-98 (pages 19A1 19A6); 2) the pathology report (pages 19B1 and 19B2)
This aged male giraffe had a long history of lameness and hoof problems. The medical records entry made by Spelman on 25November 251997 states "Hooftrim/immobilization scheduled for 12/11". On 7December1997, the medical records contain some comments by Spelman about which drugs will be used for immobilization on December 11 and the following is stated: "...after much discussion with other DVMs at North Carolina and San Diego Zoo/WAP (Drs Mike Loomis, Jack Allen, Meg Sutherland-Smith, and Pat Morris), it was decided to use the same combination in this male..."
On 11December1997, Spelman notes that the giraffe was not sedated enough by the drugs to perform the planned procedures and "Given the lack of success with the board, the procedure was aborted". Under the comments section, Spelman states "Next time consider slightly higher doses..." Spelman's plan is "Next attempt within 8 weeks dependent upon construction schedule and consultant availability".
This animal's medical records contain no other entries about immobilizations or hoof trims. The last medical entry was made on March 9, 1998 and discusses the possible use of lupron to suppress this male's breeding or using contraceptives on the female giraffe.
This giraffe died on April 30, 1998. The information provided to the Department of Pathology by Spelman when she submitted the carcass for necropsy states: "4/30/98 Collapsed and died while being sedated/anesthetized for foot trimming and x-rays"
Necropsy revealed that while it was being anesthetized, this giraffe regurgitated rumen contents and aspirated them into its trachea and lungs. The cause of death was acute aspiration of rumen contents.
Question line 1: It is clear from the medical records that Spelman consulted several veterinarians at other zoos about how to immobilize this giraffe before the December 11, 1997 procedure. Dr. Mitch Bush, who is located at the Zoo's Conservation and Research Center, is a world-recognized expert on giraffe anesthesia and has successfully anesthetized numerous captive and wild giraffes. In fact, as documented for Case #7 above, Dr. Bush authored a chapter on giraffe anesthesia in the third edition of the text Zoo & Wild Animal Medicine (published in 1993 --- more than 4 years before Spelman's attempt to immobilize this giraffe). Did Spelman ever consult Dr. Bush about how to immobilize this giraffe? Wouldn't a competent veterinarian consult a readily available and world-renown expert on giraffe anesthesia? How many giraffes had Spelman successfully anesthetized prior to December 1997?
Question line 2: Why are there no entries for April 30, 1998 in the medical records or anesthesia records of this giraffe? What drugs did Spelman administer to this animal? What were the dosages? How many injections did this giraffe receive?
Question line 3: Could the drugs and/or dosages used on this giraffe somehow have predisposed it to regurgitating and aspirating rumen contents? Wouldn't the information regarding drugs and dosages be potentially very useful for determining anesthetic regimens to use on other giraffes in the future? Isn't the failure to record this information an indication of incompetence?
Question line 4: Were any of the drugs used on this giraffe on April 30, 1998 classified as controlled drugs by the Drug Enforcement Agency (DEA)? Doesn't the DEA require careful documentation of exactly how controlled drugs are used? Isn't the failure to keep careful records on the use of controlled drugs grounds for revocation of the license to use these drugs by the DEA?
Question line 5: On December 11, 1997, Spelman aborted the procedure when the giraffe did not become sedated enough on the drugs administered to it. This clearly demonstrates that Spelman will abort a procedure if an animal does not respond as expected to an anesthetic dose. Therefore, why didn't Spelman (and Murray) abort the procedures scheduled on the lion on October 10, 2002 (see case #14 above) when it did not respond as expected to the administered xylazine and ketamine?
Case #20 Celebes macaque (accession #104111; Pathology #1998-0191)
Case-related documents are: 1) the medical records for 1998 (pages 20A1 20A3);
2) the pathology report (pages 20B1 20B3)
This middle-aged macaque was examined on June 9, 1998 because it was due for an annual physical exam and because the animal care staff felt it was not acting normally.
The exam on June 9 revealed a large cystic mass in the caudal part of the abdomen. The next day (June 10), Spelman performed exploratory surgery on this monkey and discovered "a very large fluid filled cystic structure which appeared to extend from the uterine body". The medical records later note that "electrocautery and blunt dissection was used to release and remove as much of the abnormal tissue as possible".
Following this surgery, there are no medical record entries for June 11, 12, or 13.
The medical records contain an entry for June 14, 1998 in which Dr. Cambre states: "Euthanized. No urine production during the night or this am. Appetite remained poor."
The information provided to the Department of Pathology by Dr. Cambre when he submitted the carcass for necropsy states: "06/10/98 Surgery to remove tumor/uterus 06/11-12/98 Very weak following surgery. Abdomen distended with fluids. No evidence of urination/defecation... 06/13/98 Fresh fecal found am but no urination.....Very weak...12:33 Euthanized."
Necropsy of this animal revealed that it had a hole in the right ureter approximately 1.5 cm from its junction with the urinary bladder. The left ureter was completed transected at the level approximately 3 cm from its junction with the urinary bladder. The abdominal cavity contained fluid compatible with urine.
Question line 1: During the surgery to remove the uterus from this macaque on June 10, 1998, Spelman apparently "nicked" the right ureter and completely cut through the left ureter; the reason the macaque did not urinate in the days following the surgery is because all the urine each kidney produced passed from the surgically-damaged ureters into the abdominal cavity, instead of into the urinary bladder. What is the competence level of a veterinarian who damages both ureters during a surgery to remove a uterus? Isn't this malpractice?
Question line 2: This macaque was euthanized because of its weak condition, lack of urination, and the intra-abdominal accumulation of fluid/urine following the surgery on June 10. Therefore, isn't Spelman's botched surgery directly responsible for the need to euthanize this macaque? If the surgery had been properly performed, might this animal have recovered and survived for another few months to years?
Question line 3: Why are there no entries in this animal's medical records during the 3 days between when the surgery was performed and when the macaque was euthanized? Shouldn't this animal have been monitored closely following such major surgery? Although Spelman made the medical records entries for the day before surgery (June 9) and the day of surgery (June 10), Dr. Cambre is the person who actually performed the euthanasia and who made the final medical records entry. Where was Spelman in the days following the botched surgery?
Question line 4: Although this animal was euthanized on June 13, the medical records indicate that the euthanasia occurred on June 14 -- why?
Case #21 Spelman's Dogs
Case-related documents are: 1) the clinical pathology log for all specimens submitted from the dog named "Tucker" (page 21A1); 2) the clinical pathology log for all specimens submitted from the dog named "Kelby" (page 21B1); 3) the cytology reports for specimens from "Tucker" submitted on December 3, 1998 (pages 21C1 21C4); 4) the biopsy report for the mass removed from "Tucker" on December 3, 1998 (page 21D1); 5) the cytology report for an aspirate of a mass on "Tucker" submitted on April 18, 1999 (page 21E1); 6) the biopsy report for a mass removed from Tucker on May 12, 1999 (page 21F1)
Spelman had a pet dog named "Tucker". On July 24, 1996, approximately 1 year after her arrival at the Zoo, Spelman asked permission from Dr. Montali to have a blood sample from this dog analyzed by the clinical pathology lab in the Department of Pathology. Dr. Montali granted permission to do this as a "professional courtesy".
On the morning of December 3, 1998, Spelman submitted cytology slides and a blood sample from her dog to the Department of Pathology for analyses; the slides were made from the aspiration of a skin mass that Spelman had discovered on the dog. Both the veterinary pathology resident at that time, Dr. Jim Raymond, and I looked at the slides and diagnosed a mast cell tumor --- which is a very common skin neoplasm in dogs. Although these neoplasms are usually benign, they can be malignant. Following notification of our findings, Spelman cancelled all the examinations and other procedures she had scheduled for the Zoo's animals that day; she then brought her dog into the Zoo's vet hospital where she performed surgery on her dog including an excisional biopsy of the skin tumor as well as an aspiration of another subcutaneous mass and abdominal laparoscopy with aspiration of the liver and spleen. The biopsy and aspiration cytology slides were submitted to the Department of Pathology for examination. Several months later, Spelman submitted more slides for cytologic evaluation; she had made these by aspirating a subcutaneous mass on "Tucker". Spelman subsequently removed the mass and submitted it as a biopsy.
Question line 1: What is the Zoo's policy about employees bringing personal pets onto Zoo grounds? What is the policy about employees bringing pets to the Zoo's veterinary hospital? Couldn't Spelman have arranged to exam her dog and perform the surgical procedures on her dog at a local private veterinary hospital? Why didn't she do so?
Question line 2: Is the presence of a mast cell tumor in the skin of a dog considered to be a life-threatening emergency? Does this warrant immediate surgery or can the surgery be delayed for a few days? Why did Spelman insist on performing the surgery ASAP?
Question line 3: What are the ethics of a zoo veterinarian who cancels all the afternoon procedures scheduled for the Zoo's animals in order to perform elective surgery on that veterinarian's pet? How did this affect the health care provided to the zoo animals? How many Zoo employees' schedules were affected/inconvenienced by this?
Question line 4: How does the federal government view a situation where a federal employee uses the facilities, resources, and staff at a federal institution to conduct activities just for the personal benefit of that employee and/or her pet? Is this considered ethical? Is this considered legal? Should a person who does something like this be entrusted to serve as director of "the National Zoo" of the United States of America?
Question line 5: The mast cell tumor on "Tucker" proved to be benign. In fact, this dog lived for another 4+ years. A review of the records of the clinical pathology laboratory in the Department of Pathology reveals that, between Spelman's arrival at the Zoo in 1995 and the end of October 2003, Spelman submitted 14 blood samples, 6 cytology samples, 2 urine samples, and 1 fecal sample from her dog "Tucker" to the Department of Pathology for analyses. She also submitted two biopsy samples from this dog for histopathogic evaluation. In addition, between September 25, 2001 and February 19, 2003, Spelman submitted 3 blood samples, 1 fecal sample, and a skin swab from her other dog "Kelby" to the Department of Pathology for analyses. Doesn't this appear to be excessive? Doesn't this far exceed the level of "professional courtesy"? How much did this cost the Zoo in terms of resources and staff time? How does the federal government view such a commitment of federal resources and staff for the personal benefit of a single federal employee? Is this considered ethical? Is this considered legal? Should a person who does something like this be entrusted to serve as director of "the National Zoo" of the United States of America?
Question line 6: Spelman found time to conduct physical examinations on her pets on an annual (or more frequent) basis. Doesn't this establish that she understands the importance of conducting regular physical examinations of animals? Therefore, why were so many animals in the animal collection at the National Zoo not given their usual annual physical exams while Spelman was in charge of the Department of Animal Health? Isn't Spelman's failure to ensure that annual physical exams were conducted on numerous animals an indication of incompetent practice of veterinary medicine and/or her incompetent management of DAH (a department consisting of only10 people)? Is a person who could not effectively manage DAH qualified and/or competent to be director of "the National Zoo" of the United States of America?
I believe that the 21 cases I have outlined above clearly establish a pattern of long-standing and on-going incompetence, malfeasance, and/or malpractice of veterinary medicine by both Lucy Spelman and Suzan Murray. I hope that you agree with me. However, if you feel that you need more evidence in order to make this judgement, I have more than 20 additional cases that I have documented, and I would be quite willing to discuss these cases with the committee. My primary reason for not including these cases in this letter is that I simply ran out of time to do so.
I feel that the actions of Spelman and Murray have been detrimental to the welfare of the Zoo's animals and to the reputations of the National Zoo and the Smithsonian Institution. Furthermore, I think they disgrace the entire veterinary profession. I cannot work for or with people for whom I have no respect. Nor can I continue to work for an institution that not only allows such people to remain employed there, but also apparently condones their actions. Therefore, I have decided to resign from the Zoo and seek employment elsewhere. But I intend to remain in the Washington, DC area and thus should be available if your committee wishes to discuss anything with me. Staff at the Zoo's Department of Pathology will know how to contact me.
I still care very much about the National Zoo; I have considered it "my zoo" since the summer of 1982. One of my greatest desires is to see the Zoo once again attain a place among the best zoos in the entire world. I hope that the findings and recommendations of your committee will help bring about the changes that are necessary to put the Zoo "back on the right track".
Most sincerely yours,
Donald K. Nichols, DVM
Diplomate, American College of Veterinary Pathologists
Department of Pathology
National Zoological Park
© 2003 The Washington Post Company