Monday, February 23, 2009

Terminal surgery

Vet schools are in the news lately with a story broken today by Oklahoma State's student newspaper. According to the article, Madeleine Pickens, the wife of billionaire T. Boone Pickens, withdrew a 5 million dollar donation to the Oklahoma State vet school when an anonymous vet student told her about procedures performed as part of the training program.
“Right now, when they buy these dogs, they bring them in, and they do a surgery, put them to sleep, do the surgery, wake them up, next day, put them to sleep again, maybe take out a kidney, wake them up again, put them to sleep again, maybe break a leg, fix it, wake them up again and then they kill them,” Pickens said. “That’s barbaric. That’s what you did years ago. Medicine has changed.”
So what's the deal? That sounds terrible, and I wouldn't blame her for not wanting her money to support such a program... The problem is, it's just not true. Yes, vet schools have students perform terminal surgeries. No, they don't have them perform multiple painful procedures on the same animal and inflict harm on the animals like breaking legs.

This story brings up a lot of questions. I'll try to give a vet student perspective on the issue...

The first question is, what is a terminal surgery? Also known as non-survival surgeries, these are surgeries in which an animal is anesthetized, a surgical procedure is performed, and at the end, the animal is euthanized rather than recovered. These are usually relatively painful procedures that are not necessary for the animal's sake (i.e. at the U of MN, our one terminal small animal surgery lab consists of a gastrotomy, an intestinal resection and anastamosis, and a cystotomy, which are all procedures performed to correct problems that the animals used for the lab don't have). Most schools consider it unethical to perform unnecessary surgical procedures, then put the animals through a painful recovery. So instead, terminal surgeries are performed on either shelter dogs or research dogs that were due to be euthanized. The ultimate outcome (euthanasia) is the same, but the animals provide a learning experience for a vet student before being put to sleep. They are given the same pre- and intra-operative care that we would give an owned animal, including pain control, inhalent anesthesia, IV catheter, and fluids.

The next question is, why do terminal surgeries instead of working on cadaver animals that have already been euthanized? While we do work with cadavers fairly often (two or three times a semester, plus during the entire first year anatomy course), working with live tissue on a breathing animal is far different than working on on dead tissue. Plus, there are lots of aspects of performing surgery besides working with the tissue itself- live animals require anesthesia, and live animals bleed, and live animals can have changes in their heart rate or blood pressure in response to what you're doing. You can do an awful lot of damage with poor surgical technique on a cadaver without ever realizing it, because a cadaver can't respond the same way that a live body can.

Lots of people wonder why vet students learn by performing terminal surgeries while med students (obviously) never use terminal procedures to learn. One of the biggest differences between human and vet medicine is that, as vets, we are qualified to do essentially anything to any species (except humans) after 4 years of school. That includes surgery, radiology, oncology, cardiology, and anything else. Human doctors, on the other hand, are required to do an internship and complete a residency program in their specialty of choice after graduating from med school. Human surgeons go through 5 to 7 years of training beyond med school to learn to perform surgery under the guidance of experienced surgeons. That's not to say that vet med shouldn't consider going the same way as human med- but the extra training comes with a big price tag. Also, human surgeons may not perform terminal surgeries on humans, but they do perform terminal animal surgeries as part of their training.

That's not to say that performing a terminal surgery is an essential part of becoming a veterinarian. There are plenty of great veterinary surgeons who never performed terminal procedures. Most schools offer alternatives for students that would like to opt out of terminal procedures. There are schools that only perform survival procedures (our only required surgery at the U of MN is a survival spay/neuter surgery on shelter animals, which I did last year on little Malibu, the dog in the picture). There are schools that use a combination of observation and practicing on models and cadavers. It still isn't clear what the best method of teaching surgery is, but at least schools are recognizing that not all students feel the need or desire to perform terminal procedures to learn. Frankly, the vast vast majority of surgical procedures will be performed for the first time on a client-owned animal anyway- we have the chance to practice just a few during vet school, while all the rest will be learned after graduation.

So, to bring it back to the original topic- Ms. Pickens has her facts wrong. There is absolutely no way that the Institutional Animal Care and Use Committee (IACUC) protocols would allow schools to use animals for painful surgical procedures over and over. OSU uses the animals once for a relatively routine procedure (spay or neuter), recovers them with good pain control, and then uses them several days later for a non-survival procedure (for the same types of procedures as we do at the U of MN- gastrotomies, cystotomies, etc). There is no breaking of legs, no removal of kidneys, no recovering these dogs over and over. Ms. Pickens is right that medicine has changed- we don't do things like that today.

In these sensationalists type stories, people tend to forget that vet students are vet students because we love animals. Intentionally breaking a dog's leg so that we can fix it? That's just sick. We hate terminal procedures, but understand the need to learn everything we can from these animals who give their lives for our education. We cry. We kiss their heads. We tell them thank you and we're sorry. And we use the knowledge we gain from their bodies for all the animals we'll perform those procedures on in the future.

(For the record, I opted out of the terminal surgery.)

Update: Part II of this post is here

26 comments:

twelvetigers said...

Thanks for the post - we're glad to have some support from students elsewhere. :)

Ashley - 3rd year at OSU said...

Thanks for writing such a wonderful blog. It makes me feel so good inside to see other vet students around the country stepping up to say that there is no way we (as future veterinarians) would ever do anything to inflict pain and suffering on animals. I wish you the best as you continue your training.

Heather-OSUVM said...

Thank you, Megan, for your wonderful blog. It means a lot to all involved in OSU's Vet Med program to know that other vet students are out there supporting us!

Laura said...

Thank you Megan- I blesses me to see that other veterinary students are hearing what's going on and taking a stand. Thank you for your support and detailed explanation.

Jill said...

Thanks for explaining the issue so well!

Janine said...

Very well written article! Thanks from another OSU vet student.

Anonymous said...

Actually, you're wrong, the IACUC can approve "painful" surgeries and/or means of killing the animal in a non-survival experiment. Granted, it takes a lot more proof and justification but it can be approved if the procedure is necessary for statistical or clinical significance hence the reason why decapitation is allowable for a means of "euthanasia" in some rat experiments.

The IACUC is in place to make sure abuse does not occur; however, the irony is that they do not see death as a form of abuse, which it obviously isn't exactly humane or ethical.

Now, I'm not saying that you're wrong in what you say; but, I am saying that you need to get your facts straight when it comes to an IACUC's allowances with regards to experimentation with what they do and do not allow.

Take care,

Ryan

Megan Watland said...

Ryan- I won't pretend to know the IACUC regulations in relation to experimentation or research, only in relation to the type of procedures that we perform in the terminal surgery lab. Even at the U of MN, where our animals are not recovered (versus the Oklahoma State program, where the animals are recovered once following a spay/neuter and euthanized after the second surgery), IACUC limited what and how many procedures were allowed to be done on our animals. Three procedures per animal, period, and only the three procedures I mentioned in my post. After euthanasia, we are allowed to practice other procedures, but while the animals are alive, there are big big restrictions.

Chris Schommer said...

If you are going to post something insulting, please use your real name and I will let it stay.

If you chose to remain anonymous, I will delete it in a second.

Anonymous said...

Megan,

I guess the worry at hand is whether or not these animals are being intentionally harmed in order to produce an injury for which the students can work.

For instance, if a veterinary student is required to show a proficiency in proper treatment of a broken limb does the school wait for an animal with a broken limb to be presented or does the school cause the injury and then heal it?

There's a huge difference between the two circumstances. The OSU Veterinary School has already admitted to buying animals from kennels, which are presumably the same kind of kennels that essentially farm animals for other kinds of experimentation, for the use of study; so, why wouldn't they perform the latter of the two examples?

Ryan

Anonymous said...

Oh, and the sensationalist comment was made by me as well. I forgot to add my name.

I didn't mean to be rude so much as I did to point out that accusing one of sensationalism but then reverting to the same kind of talk is off base.

The author's convictions on animal welfare came through without the last lines, just a critique of the post.

Ryan

Chris Schommer said...

Ah, thanks Ryan. I appreciate your thoughtfulness. This is the quote in question then:

"We cry. We kiss their heads. We tell them thank you and we're sorry. And we use the knowledge we gain from their bodies for all the animals we'll perform those procedures on in the future."

Megan Watland said...

Ryan- yes, I see your point. If Ms. Pickens were right, and OSU was inflicting harm on these animals in order to have students repair it, I would be just as horrified as her. However, that's simply not the case (you can see comments from current OSU students in the article that I linked to at the top of the post detailing what the actual program consists of).

I can tell you how we do things at the U of MN. When we do terminal procedures, they are performed on healthy dogs, and we don't inflict tissue trauma in order to repair it. We open the dogs, one group member cuts into the stomach, then sutures it closed, one cuts into the intestine, then sutures it closed, and one cuts into the bladder, then sutures it closed. Then the animal is euthanized. We don't repair damage that we inflict, a la the horrible Grey's Anatomy pig stabbing episode. We perform procedures as though we were, say, removing a bladder stone- there just isn't a stone there to remove.

I just finished my orthopedic surgery lab set, and two of the three labs were done with plastic bone models, while the third used limbs from the dogs euthanized during the terminal surgery labs last semester. The bones are broken post-euthanasia, not prior to it.

We do a lot of learning on animals presented to the teaching hospital (this is the purpose of our final year of clinical rotations- hands-on learning with client-owned animals), but there is no way to ensure that every student will happen to be on their surgery rotation when a dog with an intestinal foreign body comes in, or a dog needs a bladder surgery, or the like. We see what we can, but to ensure that all of us enter clinics with a baseline level of knowledge, we rely on labs taken during our first three years.

Megan Watland said...

My sentence about crying, etc was not intended to be sensationalist- just describing how the lab really is. When I was exploring whether or not I should do the terminal lab, I asked someone in the class ahead of me what she thought of it, her response was, "Everybody cries. It's worth it, but everybody cries at the end."

People are quick to jump to the idea that because vet students do it, we enjoy it. So so so not true. We can accept the importance of the procedure without being comfortable with the euthanasia at the end.

Anonymous said...

Megan-

So, you don't believe that making an incision into the stomach or intestines is considered tissue trauma?

Furthermore, it seems as if you're cutting hairs. Technically, all of the procedures you mentioned are being done in one fell swoop ergo, I guess, it's considered to be one grandiose procedure; but, still, more than one thing is being done to the animal which could be seen as putting the animal through a lot of trauma as opposed to minimal trauma.

Granted, by performing all of the procedures at one time, the number of animals euthanized is less, but is it ethical? I understand the argument that operating on living tissue is tons different than performing on non-living tissue, but suturing and sewing techniques hardly warrants the life of an animal (my opinion, of course).

The fact that you admit that there's no guarantee that all students will get a gainfully educational experience during their clinical rotation actually leads me to believe that injuries are purposely inflicted for the benefit of knowledge, simply because the school would want every student to have the same experiences and opportunities.

Anonymous said...

Megan,

I don't think that vet students (or medical students involved in basic science research for that matter) enjoy terminal experiments.

I presume (and have been told) that it's a necessary evil that some people choose to take on despite the chastising of others.

It's all very muddy, and, as with all things, some folks look at these kinds of ethical dilemmas in black and white while others tend to see the grays.

-Ryan

Chris Schommer said...

Hi every one, make sure you also read Megan's second post on this subject, that touches on many of these issues. It is a very muddy and sensitive topic with lots of split hairs!

Megan Watland said...

"Technically, all of the procedures you mentioned are being done in one fell swoop ergo, I guess, it's considered to be one grandiose procedure; but, still, more than one thing is being done to the animal which could be seen as putting the animal through a lot of trauma as opposed to minimal trauma."

Yes, but the difference is that the animal never has to experience the pain inflicted by the procedures. There are well anesthetized, both with pre-op analgesics and intra-op analgesia and anesthesia. What is being charged in the OSU case is that animals are operated on, recovered, operated on, recovered, operated on... That's what I'm referring to as "multiple procedures". Even with great pain control, recovery from a broken leg or an cystotomy will be painful.

We do inflict tissue trauma, but the animals are never conscious or aware of the pain. Without consciousness, there is no pain.

Megan Watland said...

"but suturing and sewing techniques hardly warrants the life of an animal (my opinion, of course)."

Agreed- my suturing education involved many bananas, some pig's feet from the grocery store, an orange, a flesh-colored jello-y blob of fake tissue, and a fake uterus made out of a latex glove. The mechanics of suturing isn't what we're practicing with a terminal surgery. Every type of tissue and each organ has a different type of ideal suture pattern and technique- you close a bladder differently than you would close the stomach, for example. A banana will never give you that level of practice. Basic knots and patterns, yes, but not what layer of tissue needs to be incorporated in each bite of the needle, or which tissues need an inverting versus everting patterns, or things like that.

Also, we are practicing the incision itself- where do you cut to avoid the blood and nerve supplies? How do you keep the stomach from slipping back into the abdominal cavity as you cut? Do you always cut through every tissue layer, or do you leave some intact? How do you know which tissue layers you've cut through? Again, I can practice holding a scalpel and making a nice even cut into the skin of an orange, but once you master that, the only way to continue developing your skills is to try it on actual tissue. The body gives far more challenges for surgery than you expect!

Anonymous said...

Well, the problem with all of this is your assumption that the animals cannot feel pain while under the influence of medication. You seem very convinced; however, there really isn't any way possible for you to know whether or not the animal is feeling anything; for, the animal could never out and right tell you whether or not the anesthesia and analgesics actually affects their consciousness.

It's purely speculative when it comes right down to it, which is what causes this entire ethical conundrum. Who are we to determine whether or not a species we cannot communicate with feels the pain that we administer? Of course, that's the hubris of humanity.

Sure, you can look for signs of pain but what if the animal is experiencing paralysis during the operation? What if the drugs administered throughout surgery in some way affected the animals ability to show "signs" of pain afterward? The IACUC makes those who handle animals take tests in order to teach them "signs of pain," but (as with humans) no animal is alike and pain can be very subjective.

I think it is good of Mrs. Pickens to withdraw her funding until she is completely aware of what procedures go into educating veterinarians. I think she probably made a knee jerk reaction as well, but that's not to say that what she was told might not be true. Because, it may very well be the truth and OSU may have some people not abiding by IACUC and AWA guidelines.

After all, you would think that if somebody were donating that sum of money somewhere that they would be fully aware of how and where that money was being spent.

-Ryan

Megan Watland said...

"You seem very convinced; however, there really isn't any way possible for you to know whether or not the animal is feeling anything; for, the animal could never out and right tell you whether or not the anesthesia and analgesics actually affects their consciousness."

Funny, this argument used to be used to defend not providing analgesia or anesthesia- since animals (and young children) don't have the power of language, they don't have true consciousness and thus don't need pain control. It's a bit much to get into here, but I encourage you to do some research into nociception and anesthesia/analgesia. We do know a lot about how pain is transmitted in the body, and the pain control methods used for animals today are evidenced in improved wound healing, faster recovery from surgery, fewer surgical complications including post-surgical infections, and faster return to full activity. It's a super interesting (and growing) body of knowledge.

I know I said that without consciousness, there is no pain, but I didn't mean to imply that pain control in animals relies only on making them unconscious.

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