Susan was hospitalized for three days after giving birth. She was treated with ampicillin trihydrate on arrival to the hospital and for the following three days. She was also given dextrose via an IV. Dextrose was given again three and five days later. One-half dose of laxative was given on day five and six after admission. Ampicillin treatment was started again on day 13 post-admission and continued for one more day. On days seven and 12 post-admission, she was treated with an oral nutritional solution, the composition of which was not recorded in the records. Through day 17 post admission, no diagnosis had been recorded in her medical record. Treatments were administered by several different individuals, but it was not possible to determine their identity by examining the records. On day 17 post-admission, she was examined, for the first time since parturition, by a doctor. A diagnosis of acute gastrointestinal obstruction, with secondary dehydration was made, and a three-day course of full dose oral laxatives and rehydration therapy begun. All other therapy was stopped per doctor's orders.
Perhaps you are wondering just what hospital Susan was admitted to because there some are problems with the diagnostic and treatment plan she received. Consider this: On day 25 postpartum, she was sold for slaughter due to failure to fully recover. Yes, Susan was a dairy cow. If you did not figure this out reading the paragraph the first time, please re-read it. Knowing Susan was a cow makes the story seem more reasonable, because we all know it is pretty hard to give sick cows the same degree of diagnostic scrutiny and care a human patient would receive in a hospital. Perhaps it is more reasonable for a cow, and perhaps stories like this are really common for bovine patients, but we can still do better.
The big challenge we face, of course, is economics. Typically, most ill cows are not examined by a veterinarian, and certainly not examined for multiple days in a row, because it is costly and maybe even unworkable on many farms. As a result, we veterinarians have designed treatment protocols which are a way to flow chart the diagnostic and treatment processes. There are a few problems with this approach. First, it is impossible to design a protocol for every possibility in a biological system, so protocols need to be simplified to consider only the most likely diagnoses. Second, robot-like adherence to protocols removes human judgment. No two individuals, and thus no two cases, are ever the same, and many times human judgement is needed to customize treatment. Third, many different individuals may administer treatments, and there is often no standardized training in diagnosis and treatment. Fourth, adherence to protocols is often dismally low. As a result of these problems and others, drugs are often used inappropriately. Treatments are sometimes sporadic and ineffective, and sometimes treatments are unnecessary and costly. Dairy owners often understand few details of how drugs are being used on their farm.
Improving oversight can be accomplished by doing a drug use audit. The audit starts by examining treatment records and then comparing actual treatments to protocols. This process usually opens a can of worms, as in the story above, because one often finds diagnoses and treatments are not faithfully recorded. Improving recording may be necessary before the audit can be continued. Once we know treatments are being recorded correctly, we can examine the records for compliance. The idea is to determine if the actual treatments administered are close to the treatments outlined for specific diseases in the treatment protocols. One way to conduct an audit is to randomly select a few cows, record the animal ID, and the answer these questions: What drugs were used? Were the protocols followed? Were records kept correctly? When did milk go back in the tank? Was the milk withholding period observed the same as recommended? What happened to the cow? If sold or died, was an appropriate reason listed in the records? Were slaughter withholding recommendations followed? Was there extra-label drug use, and if so, are there valid, specific protocols for use, and is there a written, valid Veterinary Client Patient Relationship (VCPR) on the farm?
Most likely there will be significant discrepancies between what was done and what was supposed to be done. This may be OK in some cases, but in most cases discrepancies may represent improper or ineffective drug use. This is expensive, wasteful, sometimes illegal and is not responsible drug use. There may be a variety of root causes including: inadequate training, language barriers, perceived or real lack of time, environmental challenges, lack of accountability, lack of proper tools and more. Further investigation to find and address the root cause is needed. Just about any farm that uses drugs for treatment of ill animals may find benefits from periodic drug audits. Even farms without employees may benefit. It behooves us all to use drugs responsibly. It helps our cows when we use drugs effectively and appropriately. It saves you money, too. Ask your veterinarian to help you get started.
Jim Bennett is a dairy veterinarian at Northern Valley Dairy Production Medicine Center in Plainview, Minn. He and his wife, Pam, have four children. Jim can be reached at bennettnvac@gmail.com with comments or questions.