Tuesday, February 24, 2009

Terminal surgery part 2

Okay, I know what you're thinking. I write a big long post about why I think terminal surgeries are justified practices in vet schools, and end it with "but oh yeah, I opted out anyway." So what's the deal? Cognitive dissonance?

It wasn't an easy decision to make. I spent a lot of time arguing with myself about it. I actually started off very much in support of performing the terminal surgery, way back in my senior year of undergrad when I wrote an ethics paper about why I thought the experience was both ethically justifiable and unequivocally the best way to learn surgery. We get exactly one opportunity to perform a gastrotomy, cystotomy, and intestinal resection/anastamosis, and that's during the terminal surgery lab. You can learn the techniques and approaches from a textbook, but until you actually perform the procedures, you really don't know what you're doing. It's a bit like the difference between taking the driver's ed class and getting behind the wheel for the first time- you know the rules and the general idea, but actually controlling a car is a whole other story.

So why did I decide not to do it? There were a few reasons, some of them logical and others emotional. My biggest logical reason was that I'm aiming for an internship after I graduate, which not all students plan to do. An internship will offer me the mentorship and guidance that I'll need as I perform surgical procedures for the first time. If a student isn't planning on an internship, the value of performing the procedures during the terminal surgery is much much greater, as it's the only time they'll do them under strict supervision before doing them on someone's pet. But for me, the value drops- I'll (hopefully) have the opportunity to have some hand-holding through my first surgeries with a good mentor.

Secondly, opting out of the terminal surgery lab doesn't mean I'll graduate without ever having done surgery on a live animal- the U of MN and Animal Humane Society give us the wonderful privilege of performing spays and neuters during our second year surgery course and during a fourth year elective small animal surgical rotation. Tissue handling, suturing, and aseptic technique can all be learned during survival procedures.

Lastly, like I said in my previous post, the vast majority of surgeries will be performed for the first time on a client-owned animal. We can only do so much in vet school, even with terminal procedures as part of our program. Some people react to that by insisting that we take advantage of every opportunity provided us in school to learn procedures on unowned animals so that at least not everything we do will be learned on client-owned animals after graduation. My reaction was that I'll need some serious mentorship after graduation regardless of whether or not I've performed a gastrotomy on a terminal surgery patient. Having performed one or two more procedures on a live dog is good, but what about all those other procedures I'll do for the first time on client's pets? I'd better get comfortable with the idea that I'll be learning on people's loved ones, since it will happen regardless of how much I get to do in school.

On the more emotional side, I was much more attracted to the alternative that the U of MN offered than I was to the terminal surgery itself. The alternative consisted of carrying around a pager for the teaching hospital and getting called in when a pet was heading into surgery for an abdominal surgery of some sort. Then we got to scrub in and watch while one of our clinicians, residents, or interns performed the surgery. The disadvantage was that I didn't get to do any cutting. The advantage is that, rather than seeing procedures performed on a healthy animal, I got to see what happens to the stomach when it twists in a GDV, or what happens to the intestines when a corn cob eaten two weeks ago wedges itself in the jejunum. The animals came with histories, emergency exams, bloodwork, and radiographs! It was okay for me to root for them, and be happy when the procedure went well because that meant the animal would go home with people who loved it. With the terminal surgeries, your anatamosis might look great, but the rest of the picture isn't there. You don't know what the traumatized tissue would look like, or how it feels or handles, and you don't know how well your repair would hold up if the animal were allowed to recover.

I also felt like participating in the terminal procedure was unfair for the particular animals we used- the U of MN purchases dogs that have been research animals their whole lives and are at the end of their research careers. My logical side argues that whether or not the terminal surgeries are performed, these animals will be euthanized. But my emotional side says that these dogs have already given their entire lives for the sake of human or animal research- is it fair to squeeze one more learning experience out of their bodies before they are put to sleep? Is it fair that their last memories will be of transportation to a new scary place, getting shots, having IV catheters placed? At least if they were shelter dogs, I could believe that at some point, those animals got the experience of being pets rather than just being used for the sake of science. To be fair, the U's justification for using research dogs is that shelters will never release live animals to vet schools due to the potential for bad PR for the shelter... So it's not necessarily the school's fault that they use research dogs, but that doesn't make me feel better about it.

Finally, I decided not to participate simply because I didn't know if I could do the surgery and still be able to look Winnie in the eyes when I got home. How can I believe that she is worth so much, but used-up research dogs are worth only one last procedure before death? We (as students) love the opportunity to work on unowned animals before we work on owned animals because we hate the idea of messing up a procedure on an animal that someone loves... But I also have to believe that animals have intrinsic value as well, regardless of if they have an owner. Performing a terminal surgery felt, to me, like I'd be completely disregarding or desensitizing myself to the intrinsic value of those animals. I couldn't do it, and yet I don't feel like I'll be a worse surgeon for having missed the opportunity.

I understand my classmates and fellow vet students who do perform terminal surgeries, because I know how valuable the experience is. After all, I use cadavers for plenty of learning experiences, and, in the words of Dr. Rasmussen, "A cadaver killed at the pound is just a live terminal surgery dog that was spared 24 hours of transport to the university." We all have to make decisions about the costs and benefits of the things we do to become effective veterinarians. It's a very intensely personal decision, and certainly not as black and white as some people (cough cough Ms. Pickens) would have you believe.

7 comments:

Mara said...

Well written Megan - both posts.

Anonymous said...

Thank you Megan. I really appreciate the perspective and that you're so open about both your decision and your respect for your peers.

quakk said...

hi, megan...

i'm glad to have found your post. you handle a difficult and emotional issue very well.

the topic of terminal surgeries is very important to me right now, as i've just submitted my statement of conscientious objection to the terminal surgeries in the 4th year surgery lab at murdoch uni.

the thing is, even though we have an alternate means of gaining surgical experience and of being assessed, they still require us to attend the terminal surgery pracs.

for many reasons, i question this policy. i was curious if minnesota did the same to you?

by the way, we love the pager idea. we're going to present that as an alternative to attending the "objectionable" pracs.

cheers!

scott quakkelaar
murdoch uni class of 2010

Anonymous said...

Wow. I stumbled to your previous post and now this one and as an animal lover, I'm shocked to learn about these surgeries. Because I love animals so much, I could never be a vet. I couldn't still myself to the idea of devaluing animal life for the purpose of saving 'owned' pets later. If we don't practice terminal surgery on people (ie: prisoners slated for the death penalty are equivalent to shelter dogs/research dogs slated to be PTS) then we shouldn't practice it on animals.

The pager system is a great substitute for the terminal surgery. Mentorships, internships, observation, residencies should be instituted. Learning can occur via other methods, as you have pointed out.

Finally, it is funny that the question of ethics arises in regard to animal research/practices. We don't have similar ethical questions about human research/practices as our society sees it as blatantly unacceptable.

We need to realize that other living beings have the same value as humans do, and treat them as such.

Thank you for your thought out perspective. But to enact change, we can't just rationalize away practices such as terminal surgery by usurping ourselves of responsibility.

Blaire said...

I too stumbled upon this blog and I I appreciate everything that you have to say.
I am a veterinary student at Western University of Health Sciences and as such, this issue really strikes a chord with me.
I chose to attend Western because of their Reverence for Life philosophy. We do not perform any terminal surgeries (All of our experience is in clinics, assisting with and performing real surgeries) and all of our cadavers are willingly donated to the school by their owners after natural death or euthanasia.
I definitely understand where you are coming from with not being able to "Devalue" one dog in order to maybe save one down the line that has "More value" because it has an owner.
I am glad to hear that this was such a big deal to you, and I am glad to hear that you opted out because I, myself, could never perform a terminal surgery. I really do have a difficult time understanding how anyone could. It just seems completely contrary to everything that we, as veterinarians take an oath to do.
Thank you for your explanation and rationalizations and other options that you laid out for people. I'm sure that there are many people that are in the same boat; not wanting to perform these surgeries, but not sure what to do or how to go about saying no to them.
People must keep an open mind to alternatives to these procedures; just because it's the way it's always been done doesn't make it right. With progress comes change.
Thank you again for the insight.

Anonymous said...

*sigh*

I really like all the words here, and as a vet student I also think about this often. I could not place more value on an "owned" dog than an "unowned" dog.

It's hard to argue against the "they would just be put to sleep in the shelter" argument though...

Megan said...

No one says you have to argue against the fact that they would just be put to sleep at the shelter anyway... I feel like if you think you could have that discussion with your future clients (i.e. if a client asked if you performed terminal surgeries, would "They would have been put to sleep anyway" feel like enough justification to you?) and be okay with it, then that's fine.

As an update for all reading this discussion, I performed about a dozen abdominal explores/gastrotomies/enterotomies on client-owned animals during my internship and they all did just fine! I also did my first amputations, mass removals, skin grafts, cystotomies, biopsies, etc on client-owned animals and they all did just fine too :) Develop your good tissue-handling and surgical skills during your spays and neuters, and the techniques you learn will carry you through just about any other surgery.