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Not your average exam

In cruelty cases, make sure your veterinary evaluation will hold up in court

From Animal Sheltering magazine March/April 2016

In potential cruelty cases, veterinarians need to know what to look for in the exam and how to document their findings.Along with detailed, objective notes from the veterinarian, photographs and even video taken during the exam provide important evidence of an animal’s condition.If starvation is suspected, give the animal food and water, and document her response (with video if possible). An animal who is just hungry, not sick, will probably devour her food, and that distinction could be important in a court case.The veterinarian should document every part of the exam thoroughly, whether she is noting the age and location of old injuries or giving the animal a body condition score.Even when an animal is taken from a suspected cruelty situation, veterinarians need to keep an open mind about all the reasons that could have caused the animal’s condition.Details that might not be relevant from a medical perspective—such as old scars indicating that a dog has been used in fighting—could be important from a legal perspective.

When veterinarian Pamela Schrager was chief of emergency services at Friendship Hospital for Animals in Washington, D.C., in the late 1990s, some of the most heartbreaking cases she worked on were the ones that came in after hours to the city’s only 24-hour emergency animal clinic.

Humane law enforcement officers like Adam Parascandola would bring in animals from alleged cruelty situations to be examined and treated—the victims of starvation or the dogs rescued from fighting operations.

Schrager had never dealt with cruelty cases before her post at Friendship. Parascandola, now director of animal protection and crisis response for Humane Society International, was new to his position at the Washington Humane Society. The field of veterinary forensics hadn’t yet been developed—the first papers on the subject wouldn’t be published for another few years.

Schrager recalls looking for information about how to use veterinary science to answer questions that would be relevant during a cruelty trial—but there weren’t any. “I would get called into court, and [the defense] would tear me apart because of the way a record was written,” says Schrager.

She and Parascandola were motivated to become more effective. Throughout about eight years of working together and evaluating each experience, they figured out how to best conduct veterinary exams for cruelty cases that would hold up later in court, where a veterinarian is usually a key witness.

Since then, the veterinary forensics field has grown; as more people become certified forensics veterinarians, more animals will ultimately benefit. But if you unexpectedly find an animal from an alleged cruelty case in your exam room, Parascandola stresses that you don’t need a forensics certification. In most cases, any good veterinarian can perform an adequate cruelty exam, he says, as long as she knows what to look for and how to document her findings.

Getting in the Mindset

When you’re confronted with an animal from a possible cruelty case, you have to wrap your brain very differently around what is important in your exam and how you write up the record, says Schrager. You need to consider details that wouldn’t normally be relevant from a medical perspective, because they could be important from a legal perspective.

Melinda Merck, a forensic veterinarian who helped spearhead the field in the United States and author of the second edition of Veterinary Forensics: Animal Cruelty Investigations, says that it’s helpful for vets to think of the animal as not only a victim, but also as evidence. And evidence needs to be recorded, so photographs and possibly videos of the animal and the exam are important. Detailed, factual, objective notes are vital.

Whatever you write in these records “is going to end up in court,” says Parascandola.

It can be hard to stay neutral when you see animals hurting, but in court, an objective vet is more credible to a judge or jury than one who jumped to conclusions, says Schrager.

“It’s easy to get swept up in it and be like, ‘OK, let’s prove how horrible this person is.’ You’ve got to remember that you need to look back and question and remain … disconnected, very professional, to give yourself enough credibility to actually help the animals out.”

Parascandola adds that the vet’s goal in a cruelty case exam should be to find out what has caused the animal’s condition, not to determine whether abuse has occurred—that’s the job of animal control officials and prosecutors.

Sometimes, investigators will find out that situations that seem like deliberate cruelty are really due to an owner’s lack of resources.

“It can be a very fine line between ‘This is an owner that needs education’ and ‘This is an owner that needs prosecution,’” says Parascandola. When cases involve a lack of resources, it’s more beneficial to provide owners with information than bring them to court.

Performing the Exam

In a cruelty exam, you’ll perform a complete physical examination, and “based on what the alleged events were, what the alleged cruelty is, that’s going to direct your examination and further diagnostic testing,” says Merck.

Remember to keep an open mind about all the reasons an animal could have ended up in her condition. What you note during the exam helps paint a picture for the jury about the animal’s condition and care she’s gotten. Anything you can note quantitatively or describe objectively is useful in court, says Schrager.

Note the animal’s demeanor, record any odor or other oddities you notice from the coat, check for external parasites and get an accurate body temperature. Give the animal a pain score, which most vets should be accustomed to rating as part of their normal work.

Noting that a dog was wagging her tail and rolled over to show you her stomach, smelled like gasoline and had black material on her underside, was covered in ticks or had a body temperature of 98 degrees helps show the court the condition of the animal.

Should the case go to court, details like these can be useful to a prosecutor—for example, if the defense claims the dog was aggressive (the behaviors described above reflect an easy-to-work-with dog), was always indoors with the owner (the gas smell could suggest otherwise) or was overheated (98 is a low temperature).

Getting an accurate weight is also critical. Sometimes, if a dog is squirming around or has been weighed on a previous visit, you might not get a precise weight that day. But in a cruelty exam, you need to, because you may need to watch an animal’s weight after treatment to see how it changes—for comparison in a starvation case, for example.

You should quantitatively and objectively evaluate body condition. You can’t simply note that “he’s skinny,” Schrager says, because “well, what’s skinny mean to you?” Schrager recommends the Purina system, which rates cats and dogs from emaciated to grossly obese on a 1 to 9 scale. For example, a score of 1 describes an emaciated dog whose body condition matches this description in the Purina chart: “Ribs, lumbar vertebrae, pelvic bones and all bony prominences evident from a distance. No discernible body fat. Obvious loss of muscle mass.” You should record the number rating and a description in your notes. If you record a description like that, it’s seen as completely objective in court, says Schrager.

It’s also important to note previous wounds and scars. In a dogfighting case, if a dog has scars that appear to be a couple of weeks old, and others that seem to be more than two months old, plus fresh bite wounds, it could mean the dog was fought on multiple occasions.

Done right, the picture you paint of how an animal looks “can’t be debated or contested,” says Schrager.

Completing the Workup

Most of the tests you’ll do as part of your workup, or diagnostic examination, will be based on what the alleged cruelty was.

Perform a heartworm test for a dog and a fecal flotation to test for parasites, which can give you a better idea of the animal’s underlying condition and the quality of care she’s gotten in the past.

X-rays can be very telling. If you suspect past abuse, skeletal X-rays help outline old fractures and trauma. In starvation cases, stomach X-rays may show sand and dirt, because the animals were trying to scavenge whatever they could find, and sometimes they can reveal even more. Schrager recalls a litter of puppies whose X-rays showed horrifying evidence—the bones of their other, dead littermates in their stomachs. The surviving puppies were so hungry that they had eaten their littermates who had already died.

“That’s something you don’t know unless you take an X-ray … and that’s fairly compelling evidence in a court of law,” says Schrager.

If starvation is a possibility, another crucial part of the exam is to provide the animal with food and water and see how she responds. When you offer food and water for the first time, record it with video, adds Merck.

Generally, with starvation cases, the defense will argue that the dog’s skinniness was caused by illness, not underfeeding. The dog’s response to food may indicate otherwise; it’s an easy way to rule out sickness, without running “a million tests,” says Parascandola.

“The first difference between a sick dog and a starving dog is that a sick dog is not hungry, and a starving dog is,” says Schrager. So, if the dog devours the food right when you set it down, she’s probably not sick.

Writing the Record

Vets tend to write their reports using medical terminology, but “we need our vets to write reports in plain language,” says Parascandola, so laypeople, like the judge or jury, can understand the case.

You can follow the subjective, objective, assessment and plan (SOAP) note format of veterinary records, but you’ll have to make some adjustments.

For the subjective section, normally you would include your opinions and the animal’s history, but as the section title says, that’s subjective information—often the very issues being contested in court—so Schrager encourages vets to put as little information there as possible.

For example, an animal control officer could bring a dog to a vet and tell her that a neighbor saw a kid beating the dog in the front yard, but he also thinks the dad beats the kid, and the dog was lying in the yard with his leg dangling and wasn’t taken to the vet.

If you write that into your medical record, “it shows bias and sort of taints your entire evaluation of the animal,” says Schrager, because it’s based on unverified information.

In that case, Schrager says all she would write for the subjective section is “Patient presents for evaluation.”

“What led up to him needing to be evaluated—that’s [the officer’s] job to sort out,” she says.

For the objective section, which contains notes from the exam, write what you see, not what you think. Be descriptive and quantitative, and stick to the facts.

In the assessment section, where you make your diagnosis, consider all the possibilities, and remember to remain unbiased. Even if a dog is thin and has devoured the food you gave her, don’t immediately label her a victim of starvation. Instead, note the possibilities: a lack of caloric intake, underlying metabolic disease or endocrine disorder. Later, if the evidence points to starvation, you can record that.

“You need to show the court you’re being objective and considering all the possibilities,” says Schrager.

Next comes the plan. In all cases but starvation, you’ll treat the patient as you normally would. In starvation cases, you shouldn’t provide any treatment besides giving the animal food, because you want to prove the animal can gain weight just by being fed, Schrager says. Even deworming an animal could affect the results; if a starved animal gains weight after being dewormed as well as fed, the defense could argue that the animal was underweight because she had worms, not because she was starved.

Instead, feed her for two weeks, documenting any weight fluctuations. Then deworm her, says Schrager. Of course, err on the side of caution. “If you think it even remotely threatens the patient” to only give her food, provide the other treatment that is needed, says Schrager.

Ideally, with appropriate treatment, the animal will make a full recovery, and if investigators and prosecutors determine there was cruelty, the abuser will be tried in court. But sometimes it can be a long time—a few years, even—before the court case happens. It’s the responsibility of animal control officers and prosecutors to help prepare the veterinarian for trial.

When you testify, the defense could go through every little detail of your report. It’s important to write objective, accurate notes that can withstand examination and questioning, because you could be on the stand for a while.

Schrager recalls one case where a dog was so covered in maggots that his eyeballs had decayed. The defense attorney had her on the stand, but Schrager thought there really wasn’t anything to debate—the cruelty in this case was pretty clear-cut.

“She kept me up there for 13 hours testifying about maggots,” says Schrager.

In the end, however, Schrager’s hard work paid off. “That one, we got a conviction on,” she says. “Eventually.”

About the Author

Colleen Jaskot is a former staff writer for Animal Sheltering magazine at The Humane Society of the United States (HSUS). Prior to working for The HSUS, Colleen wrote for various newspapers and news wire services while getting a journalism degree from the University of Maryland.