4
Review of Individual Animal Deaths at the National Zoo

Part of the charge to the committee was to examine scientifically the causes of recent animal deaths at the zoo. The committee evaluated available documentation on the care provided to 33 animals at the Rock Creek Park facility and to 15 animals that were housed at the Conservation and Research Center (CRC). Those cases included the recently publicized animal deaths referred to in the statement of task and a random sample of animals in the megavertebrate collection that had died from 1998 to 2003. The committee evaluated available written records in each case; e.g., medical records, pathology reports, curator reports, keeper reports, Specimen Records, euthanasia-request forms, and internal zoo memoranda and reports. In each case the committee based its evaluation on published guidelines and literature and federal statutes. If guidance was not available from these sources, the committee relied on professional judgment as noted in the text.

Rather than focusing solely on the events directly associated with the animal’s death, the committee reviewed the care each animal received throughout its life. The committee chose this approach for several reasons, foremost being the many instances where the written records pertaining to the events surrounding the animal’s death seemed incomplete.

The committee found recordkeeping deficiencies in 17 of the 48 cases reviewed (see Tables 4-1 and 4-2); the majority of deficiences involved medical records. However, since most of the records evaluated by the committee were medical and pathology records, this evaluation should not be considered a systematic examination of keeper, curator, or nutrition records. In some cases, the recordkeeping deficiencies involved the events immediately surrounding the animal’s death; in other cases, the deficiencies occurred over many years preceding the animal’s death and raise a question of whether a long-standing lack of attention to the animal’s general health contributed to the animal’s death. Because of the incompleteness of the records, the committee was unable to determine whether husbandry and veterinary procedures were performed but were not documented, or whether the procedures were not performed. This ambiguity left the committee without the information needed to make a definitive statement as to the factors that caused or contributed to the animal’s death.

Another factor in the committee’s decision to include a more comprehensive evaluation of each animal’s care was several cases where inadequate care was evident but did not appear to contribute to the animal’s death, and would not have been noted in an assessment of the causes of animal deaths at the zoo. Finally, it should also be noted that many of the animal deaths that were reviewed by the committee involved geriatric animals with multiple terminal conditions. In these cases, it is impossible to determine retrospectively whether each animal’s death was caused by a specific instance of inadequate care, the animal’s many medical problems, or a combination of both.

Due to these many confounding factors, the committee summarized the pertinent details of each animal’s history at the zoo, highlighting instances of inadequate care that were evident from the available records as well as recordkeeping deficiencies that raise unanswerable questions about the factors that caused or contributed to an animal’s death.

EVALUATION OF ANIMAL HUSBANDRY, MANAGEMENT, AND VETERINARY CARE PROVIDED ANIMALS AT THE ROCK CREEK PARK FACILITY

In evaluating the causes of recent animal deaths at the zoo, the committee initially examined the available records for 23 animals that had recently died at the Rock Creek Park facility (Table 4-1). The public was aware of these animals, which included megavertebrates and other species, from reports in the media and written comments that were submitted to the committee. The committee found that in the majority of these cases, the care provided the animal appeared to be appropriate based on the written records available to the committee. In a minority of cases, the committee found evidence of apparent inadequacy of husbandry, management, and/or veterinary care.

The committee chose to evaluate an additional group of animals whose deaths were not publicized (Table 4-1). These animals were selected by random sampling of previously unevaluated megavertebrate1 deaths that

1  

Defined as elephant, hippopotamus, rhinoceros, zebra, bear, giant panda, lion, tiger, cheetah, gorilla, orangutan, camel, giraffe, sea lion, seal, Przewalski’s horse, and oryx.



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Animal Care and Management at the National Zoo: Final Report 4 Review of Individual Animal Deaths at the National Zoo Part of the charge to the committee was to examine scientifically the causes of recent animal deaths at the zoo. The committee evaluated available documentation on the care provided to 33 animals at the Rock Creek Park facility and to 15 animals that were housed at the Conservation and Research Center (CRC). Those cases included the recently publicized animal deaths referred to in the statement of task and a random sample of animals in the megavertebrate collection that had died from 1998 to 2003. The committee evaluated available written records in each case; e.g., medical records, pathology reports, curator reports, keeper reports, Specimen Records, euthanasia-request forms, and internal zoo memoranda and reports. In each case the committee based its evaluation on published guidelines and literature and federal statutes. If guidance was not available from these sources, the committee relied on professional judgment as noted in the text. Rather than focusing solely on the events directly associated with the animal’s death, the committee reviewed the care each animal received throughout its life. The committee chose this approach for several reasons, foremost being the many instances where the written records pertaining to the events surrounding the animal’s death seemed incomplete. The committee found recordkeeping deficiencies in 17 of the 48 cases reviewed (see Tables 4-1 and 4-2); the majority of deficiences involved medical records. However, since most of the records evaluated by the committee were medical and pathology records, this evaluation should not be considered a systematic examination of keeper, curator, or nutrition records. In some cases, the recordkeeping deficiencies involved the events immediately surrounding the animal’s death; in other cases, the deficiencies occurred over many years preceding the animal’s death and raise a question of whether a long-standing lack of attention to the animal’s general health contributed to the animal’s death. Because of the incompleteness of the records, the committee was unable to determine whether husbandry and veterinary procedures were performed but were not documented, or whether the procedures were not performed. This ambiguity left the committee without the information needed to make a definitive statement as to the factors that caused or contributed to the animal’s death. Another factor in the committee’s decision to include a more comprehensive evaluation of each animal’s care was several cases where inadequate care was evident but did not appear to contribute to the animal’s death, and would not have been noted in an assessment of the causes of animal deaths at the zoo. Finally, it should also be noted that many of the animal deaths that were reviewed by the committee involved geriatric animals with multiple terminal conditions. In these cases, it is impossible to determine retrospectively whether each animal’s death was caused by a specific instance of inadequate care, the animal’s many medical problems, or a combination of both. Due to these many confounding factors, the committee summarized the pertinent details of each animal’s history at the zoo, highlighting instances of inadequate care that were evident from the available records as well as recordkeeping deficiencies that raise unanswerable questions about the factors that caused or contributed to an animal’s death. EVALUATION OF ANIMAL HUSBANDRY, MANAGEMENT, AND VETERINARY CARE PROVIDED ANIMALS AT THE ROCK CREEK PARK FACILITY In evaluating the causes of recent animal deaths at the zoo, the committee initially examined the available records for 23 animals that had recently died at the Rock Creek Park facility (Table 4-1). The public was aware of these animals, which included megavertebrates and other species, from reports in the media and written comments that were submitted to the committee. The committee found that in the majority of these cases, the care provided the animal appeared to be appropriate based on the written records available to the committee. In a minority of cases, the committee found evidence of apparent inadequacy of husbandry, management, and/or veterinary care. The committee chose to evaluate an additional group of animals whose deaths were not publicized (Table 4-1). These animals were selected by random sampling of previously unevaluated megavertebrate1 deaths that 1   Defined as elephant, hippopotamus, rhinoceros, zebra, bear, giant panda, lion, tiger, cheetah, gorilla, orangutan, camel, giraffe, sea lion, seal, Przewalski’s horse, and oryx.

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Animal Care and Management at the National Zoo: Final Report Table 4-1. Recordkeeping deficiencies noted in the records of animals that died at the Rock Creek Park facility. Animal Accession Number Recordkeeping deficiencies evident Recent animal deaths covered by the media or identified to the committee in public comments   East African Bush Elephant 26223   Orangutan 100797 X Bobcat 103175 X Masai Giraffe 104081 X Celebes Macaque 104111 X Grey Seal 104161   Two-toed Sloth 105802   Bengal Tiger 106098   Masai Giraffe 106318   Masai Giraffe 106649   Bacterian Camel 107662   Barbary Lion 107851   Barbary Lion 108413   Vietnamese Pot-bellied Pig 109080   Cusimanse 110332   Bongo Antelope 110565 X Pygmy Hippopotamus 110963   Red Panda 111967   Red Panda 113194   White-fronted Marmoset 113220 X Grevy’s Zebra 113393 X Bald Eagle 207549   Kingfisher 214083   Animal deaths selected by random sampling   Pygmy Hippopotamus 29218   Giant Panda 100357   Kodiak Bear 101108   California Sea Lion 102584   California Sea Lion 102590   Orangutan hybrid 105170   Gorilla 107566   Cheetah 110842 X Cheetah 113355   Sumatran Tiger 113442  

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Animal Care and Management at the National Zoo: Final Report occurred at the Rock Creek Park facility from 1999 to 2003 (NZP, Megavertebrate Pathology Log 1999-2003, March 2004). In these 10 randomly sampled cases, the committee found few problems with either the care or recordkeeping. The only evident problems involved the lack of a euthanasia form and a question of why an animal that had a history of injuries caused by cagemates was not relocated to a less adverse environment. In total, the committee evaluated 90% of all megavertebrate deaths that occurred at the zoo from 1999 to 2003, based on a list of megavertebrate deaths provided by the zoo (NZP, Megavertebrate Pathology Log 1999-2003, March 2004). The committee concluded that for the majority of deaths reviewed, animal care was appropriate based on the written records available to the committee. EVALUATION OF ANIMAL HUSBANDRY, MANAGEMENT, AND VETERINARY CARE PROVIDED ANIMALS AT CRC The committee was aware of only a few animal deaths at the CRC, specifically those of a Grevy’s zebra, a Persian onager, and two Burmese Brow-antlered deer (Eld’s deer). Therefore, the committee also evaluated 11 randomly selected megavertebrate deaths that occurred at the CRC from 1998 to 2003 (NZP, Megavertebrate Pathology Log 1999-2003, March 2004). Evaluation of these 15 animal deaths at the CRC, which included megavertebrates and other species, revealed many deficiencies in veterinary recordkeeping (Table 4-2). Because it is unclear whether veterinary procedures were performed but not documented or were not performed, the committee was unable to determine whether appropriate preventive and follow-up care was provided to the animals. These recordkeeping deficiencies are discussed in further detail in Chapter 5; the use of multiple recordkeeping systems by veterinary staff members at the CRC contributed to this problem. In total, the committee evaluated 57% of the megavertebrate deaths that occurred at the CRC from 1999 to 2003, based on a list of megavertebrate deaths provided by the zoo (NZP, Megavertebrate Pathology Log 1999-2003, March 2004). The committee concludes from its evaluation of animal deaths at the CRC that there are widespread and previously undocumented problems with veterinary recordkeeping at the CRC. As a result, there is much ambiguity surrounding the preventive and follow-up veterinary care that was provided to the animals. It may be that the appropriate veterinary procedures were performed but not documented, but that determination is impossible for the committee to make based on the available records. INDIVIDUAL CASE REVIEWS East African Bush Elephant - Accession #26223 Between 1997 and her death in 2000, this animal had been diagnosed with osteoarthritis and osteomyelitits, and suffered from multiple episodes of abdominal edema, skin lesions, and mastitis. In summer 1997 and fall 1998, the animal was tested for tuberculosis with trunk washes. However, from October 1998 until the animal’s death, the veterinary staff failed to test the animal for tuberculosis according to the records available to the committee. The animal’s medical record contains an entry from February 6, 1999, stating that “tuberculosis or other granulomatous disease can not be ruled out” as the cause of clinical symptoms. The animal began to lose weight, and her condition became resistant to treatment. In the month before the animal’s death, her condition deteriorated, and apparent discomfort worsened as she began to refuse food and medication (NZP, Medical Record, Accession #26223). On August 22, 2000, the animal was euthanized because of advanced age, severity of clinical symptoms, and poor prognosis. Necropsy revealed extensive pneumonia involving 60% of the lungs. The pneumonia was caused by a mycobacterial bovine infection, a type of tuberculosis (NZP, Pathology Report, Accession #26223). It is the judgment of this committee that the veterinary staff should have performed tuberculosis testing in accordance with federal regulation, but that the euthanasia of this animal was appropriate and warranted because of its deteriorating condition. However, it is not possible for the committee to form a judgment as to whether euthanasia would have been necessary if the tuberculosis infection had been discovered. The animal had a number of medical problems unrelated to the tuberculosis infection, and it is impossible to determine retrospectively whether its deterioration was caused by the tuberculosis infection or by the unrelated medical problems (such as osteomyelitis and osteoarthritis).

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Animal Care and Management at the National Zoo: Final Report Table 4-2. Recordkeeping deficiencies noted in the records of animals that died at the CRC facility. Animal Accession Number Recordkeeping deficiencies evident Recent animal deaths covered by the media or identified to the committee in public comments   Persian Onager 104834 X Grevy’s Zebra 110719 X Burmese Brow-antlered Deer 111413 X Burmese Brow-antlered Deer 113296   Animal deaths selected by random sampling   Scimitar-horned Oryx 104710   Przewalski’s Horse 105791   Przewalski’s Horse 106006 X Oryx Dammah 106054 X Oryx Leucoryx 107973 X Oryx Leucoryx 108300 X Oryx Leucoryx 109698 X Scimitar-horned Oryx 110177   Scimitar-horned Oryx 110612   Przewalski’s Horse 110627   Arabian Oryx 111021 X Orangutan - Accession #100797 This 33-year-old orangutan with a suspected intestinal obstruction underwent surgery on January 28, 2000 (NZP, Medical Record, Accession #100797). A 7-cm tumor and 30-cm section of the small intestine were removed with nearby lymph nodes. Examination of the tumor and lymph nodes revealed that the tumor was a malignant adenocarcinoma that had metastasized to the local lymph nodes. This type of tumor and its spread to local lymph nodes suggested a poor prognosis (NZP, Pathology Report, Accession #100797). Postsurgical recovery was uneventful. In March, an old wound on the animal’s neck reopened, and the animal was treated with a round of antibiotics. In early May, the orangutan had a 2-week bout of intermittently loose stools and was treated with two rounds of antibiotics. On June 18, the animal was started on a 7-day course of antibiotics, although there is no notation of whether it was to treat a recurrence of diarrhea or a reopening of the neck wound. On July 25, it is noted in the medical record that the animal was lethargic and had a distended abdomen. The animal apparently had diarrhea throughout July; five fecal screens were performed, and each fecal screening record notes diarrhea (NZP, Clinical Laboratory Report, Clinical Lab No. 2000-1949; 2000-2050; 2000-2133; 2000-2178; 2000-2194). The screenings on July 21 and July 24 (NZP, Clinical Laboratory Report, Clinical Lab No. 2000-2178; 2000-2194) both indicated gram-negative bacterial overgrowth. The animal developed progressive anorexia and vomiting (NZP, Medical Record, Accession #100797). Euthanasia was performed because of the animal’s deteriorating quality of life and poor prognosis due to metastatic intestinal cancer (NZP, Request for Specimen Euthanasia, Accession #100797; NZP, Medical Record, Accession #100797). Necropsy revealed persistent diarrhea attributed to subacute inflammation of the intestine; Salmonella arizonae was cultured from the colon (NZP, Pathology Report, Accession #100797). In the committee’s judgment, the veterinary care provided this animal was acceptable, and the euthanasia was appropriate. The failure to diagnose the Salmonella infection might be viewed negatively, but in the committee’s judgment the veterinary staff was warranted in attributing the animal’s diarrhea to complications from intestinal resection and intestinal tumors. In addition, the committee could find no fault with the decision to euthanize. However, the euthanasia-request form for this animal (NZP, Request for Euthanasia, Accession #100797)

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Animal Care and Management at the National Zoo: Final Report was incomplete in that the curator’s signature was missing, and the signature of the representative of the Department of Animal Health was dated March 2001, 9 months after euthanasia. In addition, the form indicated that the National Zoo director disapproved the euthanasia. Allegations have been made that the decision to euthanize was based on an ultrasonogram that was misread by the veterinary staff as indicating metastatic liver tumors (Nichols letter to the authors, November 11, 2003). There is no indication in the medical record, pathology record, or euthanasia form that ultrasonography was performed. The committee was charged with performing a science-based evaluation of recent animal deaths, and it is not within its purview to ascertain the validity of that claim. On the basis of the clearly documented diagnosis of metastatic adenocarcinoma of the small intestine, a recurrent history of diarrhea, and declining quality of life, it is the committee’s judgment that veterinary care and diagnostics performed on this animal were acceptable and that the euthanasia was justified. However, the incompleteness of the Request for Euthanasia form is unacceptable. Bobcat – Accession #103175 The 23-year old bobcat had a 5-year history of chronic renal disease and osteoarthritis leading to progressive inactivity. The curatorial staff, keepers, and veterinarians agreed that euthanasia was the best option for the animal and that additional procedures requiring anesthesia, such as trimming the overgrown claws, were not indicated because of the advanced renal failure and a prolonged recovery after the last anesthesia procedure (NZP, Medical Record, Accession #103175). At necropsy, overgrown claws were observed on both front paws that had grown into the adjacent footpads (NZP, Pathology Report, Accession #103175). A benign tumor was found in the adrenal cortex and a malignant tumor in the thyroid gland at necropsy that may have contributed to the bobcat’s clinical signs (NZP, Pathology Report, Accession #103175). Microscopically, there were multifocal glomerulosclerosis and tubular mineralization that resulted in the impairment of renal function. There was histologic evidence of renal secondary hyperparathyroidism resulting in fibrous osteodystrophy in the skeleton that contributed to the physical inactivity, most likely because of bone pain (NZP, Pathology Report, Accession #103175). In the committee’s judgment, based on macroscopic photographs (submitted to NAS, 12-19-2003) of the front paws that revealed a lack of local inflammation or infection, the overgrown claws appeared to be a minor component of the animal’s deteriorating body condition. The veterinary care provided this animal was acceptable, and euthanasia was appropriate and warranted. However, the medical recordkeeping was unacceptable: two different sets of medical records were supplied to the committee. Masai Giraffe - Accession #104081 The animal was first reported for front leg tenderness in May 1996 and diagnosed with overgrowth of the front medial claws in June 1997. This older male giraffe was affected by severe arthritis in his rear limbs and as a result developed severe hoof overgrowth. He was treated with several courses of phenylbutazone. At this time, planning was begun for hoof trim and radiography in the fall or winter. Anesthesia and immobilization of giraffes result in high mortality because of the giraffe’s unique physiology, and anesthesia and immobilization require construction of special restraint facilities and behavioral training of the animal (Bush, 1993). An attempt to anesthetize and immobilize the animal was made on December 11, 1997, but was unsuccessful because the animal would not cooperate and because of the physical limitations of the facility (NZP, Medical Record, Accession #104081). A second attempt to anesthetize and immobilize the animal was made on April 30, 1998; during this attempt, the animal collapsed and died (NZP, Pathology Report, Accession #104081). There are no medical records for this animal after March 9, 1998, even though the record reflects that the animal was removed from the collection on April 30, 1998 (NZP, Medical Record, Accession #104081). Necropsy revealed that the giraffe regurgitated and aspirated rumen contents while recovering from an aborted anesthetic induction (NZP, Pathology Report, Accession #104081)—one of the possible complications of anesthesia and immobilization of giraffes (Bush et al., 2002). Chronic arthritis and lameness are common causes of morbidity in zoo-maintained giraffes. The veterinary staff adequately managed the orthopedic problem for 2 years, and anesthesia was used as a last resort because of the high mortality of giraffes under anesthesia. The committee is unable to evaluate the veterinary actions of April 30, 1998, because there are no entries in the medical record after March 9, 1998, except for a note on April 30 that the animal was removed from the collection. Celebes Macaque - Accession #104111 This female Celebes macaque was first presented for examination on May 21, 1998, because of weight loss and being “not quite herself.” A “very large” firm spherical caudal abdominal mass was detected on physical

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Animal Care and Management at the National Zoo: Final Report examination on June 9; after a complete workup, the decision was made to perform an exploratory abdominal examination the next day (NZP, Medical Record, Accession #104111), which resulted in an ovariohysterectomy due to periuterine endometriosis (NZP, Pathology Report, Accession #104111). No clinical record entries were made from June 11 to 13, and it is unclear whether postoperative observation of the animal occurred. On June 14, the macaque was immobilized because of poor appetite and failure to produce urine. Testing revealed urine in the abdominal cavity, and the animal was appropriately euthanized as a result (NZP, Medical Record, Accession #104111). Necropsy revealed a number of pathologic changes, the most important of which was that “during the surgical procedure . . ., a perforation was accidentally induced in the right ureter and the left ureter was inadvertently transected” (NZP, Pathology Report, Accession #104111). In the committee’s judgment, removal of an abdominal mass is a very difficult surgical procedure, and consideration should have been given to bringing in a surgical specialist to assist. No entries were made in the medical record made available to the committee for the 3 days immediately after the surgical procedure; so it is unclear whether the animal was observed postoperatively. Although the outcome of this case if the surgery had been successful will never be known, the immediate cause of death was damage to the ureters at the time of surgical resection of the abdominal mass. Grey Seal – Accession #104161 This geriatric animal was anorexic and lethargic on August 31, 2002, with a twitch in the neck and face. These clinical symptoms were evident the next day; the animal was given antibiotics, and blood was drawn to test for West Nile virus. The animal continued to deteriorate, had difficulty breathing, and displayed neurologic signs, including twitching and involuntary eye movements. Additional testing (radiography, ultrasonography, electrocardiography, and so on) was performed on September 2, and the results suggested the animal had encephalitis; steroids and further antibiotics were administered. The animal experienced seizures that night and died (NZP, Medical Record, Accession #104161). Necropsy revealed underlying heart disease, an ovarian tumor, and an inflammation of the brain caused by the West Nile virus. The cause of death was heart failure. The animal’s advanced age, the presence of heart disease, and an ovarian tumor probably predisposed this animal to inflammation of the brain after it was infected by the West Nile virus (NZP, Pathology Report, Accession #104161). It is the committee’s judgment that the veterinary care provided this animal was acceptable. Two-toed Sloth - Accession #105802 On routine physical examination in September 1999, the sloth was first noted to have increased blood values suggestive of chronic renal disease (NZP, Pathology Report, Accession #105802). There were no followup annual examinations, and the animal was found dead in July 2001. The cause of death was acute septicemia that led to cardiac and liver failure due to acute necrotizing typhlitis and metritis. Arcanobacter pyogenes was cultured from the heart, and multiple microorganisms from the uterus. Chronic renal fibrosis evident at necropsy contributed to but was not the cause of death (NZP Pathology Report, Accession #105802). Medical records from 1987 until death were reviewed. The veterinary care provided this animal was acceptable until 1999 (NZP, Medical Record, Accession #105802). After 1999, there was an apparent failure to perform appropriate routine veterinary care and follow-up diagnostics to monitor the animal’s condition. However, this animal died from septemia, and morbidity and death from septemia can occur within days or even hours. It is plausible that there were no outward abnormal clinical signs from this animal until 24 hours before death. Bengal Tiger - Accession #106098 This geriatric animal developed hindleg weakness in 1998 because of spondylosis. The animal was treated for the next 4 years with steroids and later nonsteroidal anti-inflammatory drugs (NSAIDs). The spondylosis progressed and became severe. The animal became ataxic on September 30, 2002. The animal was euthanized on October 2, 2002, because of deteriorating clinical condition and poor quality of life (NZP, Medical Record, Accession #106098). The veterinary care provided this animal was acceptable and euthanasia warranted in the judgment of this committee. Masai Giraffe - Accession #106318 This 19-year-old female giraffe had rapid onset of anorexia, difficult mastication of food with escape of ingesta from her mouth during chewing, and bloating. The course was rapidly progressive (5 days) from onset of illness to natural death (NZP, Medical Record, Accession #106318). Necropsy revealed poor body condition with widespread serous atrophy of body fat. The teeth were markedly worn to near the gingival line with extensive food

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Animal Care and Management at the National Zoo: Final Report impacted in the interdental spaces and associated periodontitis and suppurative gingivitis. In addition, there was acute suppurative gastritis of the forestomachs caused by gram-negative filamentous bacteria suggestive of Fusobacterium spp. A terminal blood sample revealed profound hypoglycemia and renal dysfunction indicated by high blood urea nitrogen and hyperphosphatemia (NZP, Pathology Report, Accession #106318). A similar “clinical syndrome” has been reported in captive giraffes associated either with feeding diets insufficient in protein but too high in fiber (Fowler, 1993) or with chronic energy malnutrition and hypoglycemia (Ball, 2000). It is apparent that consumption of large amounts of bamboo as browse by giraffes at the National Zoo caused serious dental wear and gingival infections that later interfered with the animals’ ability to consume adequate nutrients for normal energy balance and to prevent progressive inanition.* In the wild, giraffes browse on soft small leaves of acacia and other trees and are not accustomed to diets with large amounts of roughage. In the committee’s judgment, the veterinary care provided this animal was acceptable. Because of the lack of peer-reviewed literature on the cause of the animal’s clinical syndrome, it is not possible for the committee to determine whether the feeding of bamboo browse contributed to the animal’s death. However, the diet and medical records for this animal indicate that the animal care staff failed to manage this animal’s diet appropriately. A diet change request form for this animal, submitted on February 14, 2002, and signed by the nutritionist on March 1, 2002, states that all bamboo is to be discontinued until further notice (NZP, Diet Specification and Diet Change Request Form, Accession #106318). Yet, on April 28, 2002, this animal was examined by the veterinary staff for lameness in the right front leg. The clinical note indicates this animal climbs the moat in its exhibit to gain access to bamboo, and this climbing may have led to the injury (NZP, Medical Record, Accession #106318). Masai Giraffe - Accession #106649 This 16-year-old male giraffe had a chronic history of intermittent lameness, especially in both front legs, and periodic overgrowth of the foot wall with abscess formation. In early January 2002, the animal had abnormal regurgitations and began to have “sour” breath that persisted for several months. The giraffe preferred bamboo to its regular diet of hay during its illness. The animal’s condition continued to deteriorate until he was found in sternal recumbency with extreme weakness and abdominal distention. Important clinical laboratory findings included hypoglycemia, hypocalcemia, hyperphosphatemia, and mild anemia. The giraffe died of natural causes although the Zoo staff had decided to proceed with euthanasia because of its deteriorating condition (NZP, Medical Record, Accession #106649). At necropsy, the giraffe was found to be in poor nutritional condition as indicated by reduced amounts of subcutaneous and body fat and by pericardial and abdominal serous atrophy of fat. There were focal erosions of joint cartilage of the radius, femur, and humerus. The gingiva between the molars was receded, and the interdental spaces were packed with fibrous plant material. That condition was associated with marked proliferative gingivitis that was probably related to the animal’s preference for bamboo to hay. The necrotizing suppurative frontal sinusitis probably was related to the abnormal regurgitations. The animal appeared to have died from a clinical syndrome that develops in captive giraffes fed a low-protein and high-fiber diet and has been reported in the literature (Fowler, 1993). The high-fiber diet fed to this giraffe also resulted in blunting and fusion of villae in the small intestine, which may have resulted in malabsorption of some nutrients (NZP, Pathology Report, Accession #106649). In the committee’s judgment, the veterinary care provided this animal was acceptable. Owing to the lack of peer-reviewed literature regarding the cause of this animal’s clinical syndrome, it is not possible for the committee to determine whether the feeding of bamboo browse contributed to the animal’s death. Bactrian Camel- Accession #107662 This camel was euthanized in January 2004 after at least 6 years of chronic forelimb lameness, which responded intermittently to a succession of treatments. She was housed with a male camel beginning in 1990, and copulation was noted on several occasions. She had one unborn calf in her lifetime and often had minor skin scrapes, abrasions, bite wounds, and hair loss caused by interactions with the male. A left front swollen fetlock was first noted on August 29, 1990; however, the problem resolved. In August 1997, she developed a left front lameness that continued intermittently in various degrees of severity until death. In October, she was examined with radiography while under standing anesthesia; however, no evidence was found to explain the lameness. She was treated with antibiotics for a foot abscess and later with NSAIDs for pain as the limping continued intermittently. Radiography was repeated twice in 1999, and chronic signs of arthritic changes were noted in left front joints. In March 2000, she was suffering from pelvic pain attributed to interaction with the male while in rut. Attempts to diagnose this problem *   This sentence was edited after release of the prepublication draft to clarify the committee’s views on the consumption of large amounts of bamboo by giraffes.

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Animal Care and Management at the National Zoo: Final Report definitively were unsuccessful, as radiography of her neck and distal limbs were normal. However, the zoo did not have the imaging equipment necessary to obtain spinal radiographs. The animal could not be transferred to a large-animal clinic for evaluation because she had a chronic diagnosis of subclinical cryptosporidiosis that treatment options had failed to resolve. The keeper and curator continued to assess her quality of life as it varied over the years. There were indications of “click,” “cracking,” and “popping” noises heard by the keeper from the left and right forelimbs beginning in 2001. In April and August 2002, the camel experienced episodes when it could not rise and had trembling in the limbs. In September 2002, there were several entries in the clinical notes regarding the consideration of euthanasia. Throughout 2003, the camel received a variety of treatments to address her lameness, including a glucosamine supplement that provided some relief. Also the animal was separated from the male while he was in rut, but she was not voluntarily consuming all medications placed in the feed. Late in 2003, her left front leg was progressively bowing with the knee being a few inches lateral to the foot. In January 2004, the animal’s quality of life deteriorated progressively, and the decision to euthanize was made by the curatorial, keeper, and veterinary staff (NZP, Medical Record, Accession #107662). The medical records reviewed were from June 1987 until the euthanasia of the animal on January 17, 2004. The animal received a physical examination with blood work about every 1 to 2 years. The camel had chronic left front lameness since August 30, 1997, which progressed to degenerative joint disease. Veterinary care was appropriate, with at least bimonthly checks beginning in January 2001. Complete diagnostics on the animal included radiography, joint taps, blood work, and consultations with outside experts. Treatment included multiple series of NSAIDs and chondroprotectants (NZP, Medical Record, Accession #107662). Despite appropriate veterinary care to manage the joint deterioration and pain, the camel was experiencing poor quality of life and was appropriately euthanized. Barbary Lion - Accession #107851 Starting in March 2000, this animal was reported to have difficulty in moving due to spondylosis; in April, she developed intermittent anorexia. Dysphagia became chronic and progressive despite therapies. Multiple veterinary workups failed to yield a diagnosis. The animal also developed stranguria and urine scalding. The animal was euthanized on December 4, 2000, because of severe dysphagia and deteriorating condition (NZP, Medical Record, Accession #107851). Necropsy revealed a malignant tumor that metastasized throughout the abdominal cavity and affected multiple organs. Tumor impingement on the bladder caused the stranguria, and the animal’s difficulty in chewing and swallowing was the result of abnormal nerve function caused by the presence of multiple tumors. The pathology report also noted that the ovariohysterectomy performed in November 1995 was incomplete; about 15 cm of one uterine horn was found on autopsy (NZP, Pathology Report, Accession #107851). The veterinary care provided this animal was adequate. It is the committee’s judgment that the inability to diagnose the malignant tumor was not due to a failure on the part of the veterinary team. Barbary Lion - Accession #108413 This 14-year-old lion was found dead after an x-ray procedure for chronic lameness. Several anesthetics were injected (xylazine, ketamine, and midazolam), and isoflurane was administered for 2 hours with an inhalation tube. Two immunizations were performed while the lion was under anesthesia (NZP, Medical Record, Accession #108413). He was found dead the next morning with pulmonary edema of unexplained pathogenesis. The xylazine concentration in the kidney was found to be “high”; however, appropriate control tissue (such as kidney tissue from an animal given a similar amount of anesthetic that had recovered normally) was not assayed for xylazine (NZP, Pathology Report, Accession #108413). It is not appropriate to conclude that inadequate veterinary care, such as a possible excessive dose of anesthetic, was responsible for the death of the lion because it is appropriate veterinary medical practice to administer additional doses of an anesthetic to a dangerous animal undergoing a surgical procedure when the initial dose fails to provide the desired anesthesia. Tissue concentrations of anesthetics in different animal species after death are not available in the published literature, so it is impossible to draw conclusions from the xylazine concentration in the kidney. In the committee’s opinion, the veterinary care provided this animal was acceptable. Vietnamese Pot-bellied Pig - Accession #109080 This geriatric Vietnamese pot-bellied pig was first examined on June 17, 2002, for possible ascites (accumulation of fluid in the abdomen) because of keeper reports of the animal’s “pendulous abdomen and short gait on rear legs.” A full clinical workup was performed with ultrasonography and revealed an enlarged heart, spondylosis, and a right-sided hydroureter, all attributed to clinical signs of aging, but no signs of free fluid in the abdomen. From June 17 to October 17, clinical signs in the animal varied from normal to partial anorexia; on

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Animal Care and Management at the National Zoo: Final Report October 9, keepers reported further enlargement of the abdomen. The veterinarian offered to pursue a more intensive workup; however, the medical record reflects “that keepers prefer not to work up further at this time” (NZP, Medical Record, Accession #109080, Clinical Note, October 9, 2002). On October 17, keepers reported that the animal “is worsening and is having difficulty standing.” The pattern of intermittent anorexia continued until October 24, when the pig was anesthetized and a full workup performed. Radiographs and ultrasonography revealed “a round 10 cm mass noted in caudal, ventral abdomen.” On October 25, “keepers elected euthanasia,” which was humanely performed on October 28 (NZP, Medical Record, Accession #109080, Clinical Note, October 9, 2002). At necropsy, an adenocarcinoma of the uterus, a leiomyoma of the uterus, and a leiomyoma of the cervix were found (NZP, Pathology Report, Accession #109080). It is the committee’s judgment that appropriate diagnostic steps were taken to arrive at the cause of the animal’s clinical signs, and appropriate veterinary care was given. However, the medical records indicate that the animal keepers, not the veterinary medical staff, were making the medical decisions, including when to euthanize the animal (NZP, Medical Record, Accession #109080). It is imperative that trained, competent veterinarians have the final authority and accept responsibility for all medical decisions involving animal patients at the National Zoo. Cusimanse - Accession #110332 A routine physical examination with blood work on January 10, 2001, revealed blood values suggestive of kidney disease (NZP, Medical Record, Accession #110332). Keepers in the unit monitored the animal closely for clinical signs of renal insufficiency, such as excessive drinking and urination. Increased water consumption was first noted on May 9 with normal urination, defecation, and appetite (NZP, Office of Animal Programs Daily Report, Accession #110332). The kidney disease was not followed up in this animal with more frequent veterinary examinations. The keeper reported lethargy and an unkempt appearance on Saturday, February 16, 2002. The animal was moved to the veterinary hospital for close observation of appetite, drinking, urination, defecation, and attitude. Blood work was not performed when the animal was moved to the veterinary hospital because the clinical pathology laboratory is not available on weekends. Blood work also was not performed after the laboratory opened on Monday. The cusimanse was found dead in its hospital cage on February 20 (NZP, Medical Record, Accession #110332). The pathology report confirmed nephrosclerosis with uremia as the cause of death (NZP Pathology Report, Accession #110332). The medical records from birth to death were reviewed. The veterinary care provided this animal before its admittance to the hospital on February 16, 2002, was acceptable. However, the veterinary staff did not recognize that the animal was critically ill while in their care. The animal was evaluated each day by the attending clinician, and it appeared to be bright, alert, and actively avoiding the presence of humans. However, it is the judgment of the committee that blood work should have been done on the first day that the pathology laboratory was available (Monday). The animal received less than ideal care because of a failure to perform diagnostics in a timely manner; however, it is uncertain whether this failure contributed to the death of the animal, inasmuch as it had a long history of renal failure. Bongo Antelope – Accession #110565 This female bongo antelope was first seen on November 11, 2000, for “fur loss and sore on the neck.” On December 19, the animal was put under general anesthesia for physical examination, vaccinations, and tuberculosis testing. The tuberculosis test site was observed over the next several days (December 20-25,) and was found swollen and somewhat enlarged. On January 26, 2001, the keeper reported soft stools and a reduced appetite. On January 29, the animal was reported to have watery diarrhea and depression. A physical examination was performed under anesthesia, and the animal was treated with a variety of antibiotics over the next few weeks. On May 26, the animal was seen for “weight loss with thin appearance with unclear food consumption history.” On May 28 and 29, she was reported to have “explosive watery diarrhea.” Over the next 10 days, the animal was examined by a veterinarian several times for continued loose stools and chronic weight loss, and a full workup was to be scheduled for the following week. On June 15, the animal was found to be “ataxic, with legs trembling” and was anesthetized for examination. The medical record indicates that radiographs were taken of the thorax and that a blood sample was collected. The next entry in the medical record, on June 16, indicates treatment with flunixin meglumine until further notice (NZP, Medical Record, Accession #110565). The animal was apparently euthanized on June 19 because of a poor prognosis (NZP, Pathology Report, Accession #110565). However, there are no clinical entries in the medical record after the physical examination conducted on June 15. Necropsy revealed that the animal had a leiomyoma of the uterus, which compressed the adjacent large intestine, and this condition led to the diarrhea noted in the weeks before death (NZP, Pathology Report, Accession #110565).

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Animal Care and Management at the National Zoo: Final Report The medical records are incomplete; no entries indicate the decision to euthanize the animal. It is unclear from the medical record why radiography or ultrasonography was not performed on the abdominal cavity to explore the possible cause of the chronic diarrhea. Euthanasia of the animal on the basis of the clinical observations noted in the pathology report was appropriate in the committee’s judgment; however, it is impossible to determine whether early detection of the tumor would have influenced the outcome of the case. Pygmy Hippopotamus - Accession #110963 This 9-year-old animal was found dead on January 27, 2003. The animal failed to eat all of her feed on the previous afternoon, but no clinical symptoms were evident. Necropsy revealed lesions on the brain and spinal cord and changes in the liver suggestive of acute shock caused by a viral infection of the central nervous system. This condition compromised the animal’s respiratory and cardiovascular functioning and resulted in fluid accumulation in the lungs and death. Tests for West Nile virus, equine encephalitis (western, eastern, and Venezuelan), and rabies were negative. In addition, extensive screening for toxic substances was negative, and analysis of the water quality in the animal’s pool revealed nothing unusual (NZP, Pathology Report, Accession #110963). It is the committee’s judgment that the veterinary care provided this animal was acceptable. Red Pandas - Accession #113194 and Accession #111967 On January 11, 2003, two red pandas were found dead. Necropsy revealed that both animals died from accidental exposure to aluminum phosphide, which had been used as a rodenticide in their enclosure (NZP, Pathology Report, Accession #113194; NZP, Pathology Report, Accession #111967). At the time of the animals’ deaths, pest management was the responsibility of the safety manager. It is the judgment of the committee that the veterinary care provided these animals was acceptable. The deaths of the animals were due to a lack of proper procedures, including the lack of a formal use plan for the fumigant, no approval system prior to application, and no pesticide use policy (see interim report for further discussion). White-fronted (Geoffrey’s) Marmoset - Accession #113220 This female marmoset was first seen on August 28, 1997, for a routine physical examination, vaccinations, and tuberculosis testing. She was given routine physical examinations, vaccinations, and tuberculosis testing on July 15, 1998, and all findings were normal. At her annual physical examination on July 22, 1999, an abdominal mass was detected and thought be a gravid uterus. As a result of the suspected pregnancy, tuberculosis testing was not done and no vaccinations were administered. The next entry in the medical record is from June 1, 2002, when the animal was given a dose of ivermectin. On August 19, the marmoset was taken to the veterinary hospital because of weight loss. A clinical workup was postponed until August 26 because of other emergencies. At that time, a “firm round mass” was located with abdominal palpation and radiographic examination. The mass (diagnosis uncertain) was surgically removed, and the animal made an uneventful recovery. There are no other medical record entries for August 26. On August 28, the animal was examined because “the abdominal incision had opened and the entire gastrointestinal tract was exposed.” In a second operation, a large section of the small intestine was removed. There are no medical record entries for the first postoperative day, August 29. The animal was observed, and entries were made in the medical record for August 30 and 31 and September 1. No entries are in the medical record for September 2-3. On September 4, the marmoset was anesthetized and examined because “she appeared painful and her bowel was distended.” A third operation was performed. Because of postsurgical adhesions and intestinal perforations, the animal was euthanized (NZP, Medical Record, Accession #113220). The clinical management of this case raises several questions: Either the medical record is incomplete or no annual physical examinations were performed in 2000 and 2001, despite the detection of an abdominal mass on July 22, 1999. There also is no record that tuberculosis testing and vaccinations were done in 2000 and 2001. The marmoset was seen at the hospital on August 19, 2002, and surgery was performed on August 26. There is no documentation in the medical record that this animal was observed postoperatively until August 28, when the medical record notes wound dehiscence and evisceration of the intestinal tract. After the second surgery on August 28, 2002, there is no indication in the medical record that the animal was observed on August 29. There is no documentation in the medical record of how euthanasia was performed.

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Animal Care and Management at the National Zoo: Final Report Grevy’s Zebra - Accession #113393 On May 17, 1999, this animal was examined by the veterinary staff because keepers reported that it had a distended abdomen. According to the animal’s medical record, the diet was cut from 2 lb of pellets and 2 flakes of hay to 1 lb of pellets and 2 flakes of hay (NZP, Medical Record, Accession #113393). National Zoo documents (Wells, 2000b) indicated that at some time during summer 1999, the animal’s diet was increased to 5 lb of pellets per day and later reduced to 4 lb of pellets and 4 flakes of hay, which is presumably the diet that the animal was receiving in fall 1999. However, those changes were not noted in the medical records, and no nutritionist records could be produced for the animal. On November 8, the keeper logs indicated that the animal’s diet was to be reduced to 2 lb of pellets and hay would be reduced by half, but there is no indication of what the hay consumption was previously or what measurable amount it would then be (NZP, Keeper’s Log, Accession #113417 and 113392. The change was not noted in the medical record, although the keeper logs indicated that the veterinary staff was aware of the diet change; other zoo documents also indicated the change was at the behest of the veterinary staff (NZP, Nichols and Stevens memo, undated; Wells, 2000a). Zoo documents further indicated that the diet was reduced for 3 or 4 weeks and then returned to about 4 lb of pellets and 3 flakes of hay per day (NZP, Nichols and Stevens memo, undated)(Nichols and Stevens; Wells, 2000b). However, the change is not noted in the keeper logs, veterinary medical records, or curator report. On the afternoon of January 31, 2000, the animal was seen by the veterinary staff after keeper staff saw him lying on the stall floor. The animal was sedated for examination, and intravenous fluids and other medications were administered. The animal recovered from sedation and was then locked into his stall for the night. The veterinary staff’s examination of the animal and the two other zebras it was housed with led to the veterinary staff further reducing the zebras diets (NZP, Keepers Log, Accession #113417 and #113392), though the pathology report and nutritionists examination subsequently determined that all animals were underweight (NZP, Keepers Log, Accession #113417 and #113392; NZP, Pathology Report, Accession #113393). The animal died the night of January 31, 2000, because of hypothermia with inanition as a contributing factor (NZP, Pathology Report, Accession #113393). Various internal zoo documents (NZP, Nichols and Stevens memo, undated; Wells 2000a and 2000b) generated after the animal’s death indicated that the zoo keepers, the curator, and the veterinary staff were apparently aware of the two diet changes that occurred in November and December, although the changes were not documented in the available records in a complete fashion, if at all. It is unclear to what extent the nutritionist was involved in the decisions, because no nutritionist records could be produced for the animal, although there are indications that diet-request forms were submitted to the nutritionist (Wells, 2000a). Some keeper logs pertaining to the animal were not archived, and others were improperly archived. In addition, it is apparent that substantial changes were made in the medical record of this animal, as detailed in the committee’s interim report. In the judgment of the committee, the apparent inadequacies of care contributed to the animal’s death, including the failure of the nutritionist to be involved in decisions regarding the animal’s diet, failures by all staff involved to document changes to the animal’s diet clearly, and failure of the veterinary staff to assess the animal’s body condition properly. In addition, the failure of the veterinary staff to note changes in diet that were prescribed by the veterinary staff is unacceptable, as is the incompleteness of the medical record and subsequent changes made to the medical record. Allegations have been made that attempts were made by the animal care staff to have the veterinary staff reevaluate the animal in December and January and that the curatorial staff, although aware of the lack of adequate heat in the building, had failed to act. There is no documentation in the keeper or curatorial records to indicate that the veterinary staff were contacted, nor was documentation available to indicate that the curatorial staff had been informed of the problems with the heating system in the building. The committee was charged with performing a science-based evaluation of recent animal deaths, and it is not within its purview to ascertain the validity of these claims. Bald Eagle - Accession #207549 On July 3, 2003, at about 7:15 a.m., the bald eagle was found seriously injured on the ground in the center area of its outdoor flight cage. No health problems had been reported. The bird was treated for shock and tissue trauma with antibiotics, an anti-inflammatory drug, pain medications, and fluid therapy at the veterinary hospital. Blood values were normal except for a highly increased creatine phosphokinase due to muscle and tissue damage. On July 4, the bird was anesthetized again for wound management, but it suffered cardiac arrest at 10:14 a.m. A

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Animal Care and Management at the National Zoo: Final Report catheter was placed and cardiopulmonary resuscitation with appropriate drugs was initiated, but death was called at 10:25 a.m. The cause of death was cardiac arrest (NZP, Medical Record, Accession #207549). There was no evidence cited in the pathology report to suspect any underlying disease or condition that would make this animal particularly vulnerable to a predator attack. The eagle was probably attacked by a fox, given evidence at the exhibit and the nature its wounds (NZP Pathology Report, Accession #207549). The most likely scenario is that the fox entered the cage to consume food left for the eagle, the fox was attacked by the bird, and the eagle faired badly in the resulting conflict. It is the committee’s judgment that the veterinary care provided this animal was appropriate, though it may be that failure to inspect the cage or perform necessary maintenance made it possible for the fox to penetrate the eagle’s flight cage. Kingfisher - Accession #214083 This kingfisher had been successfully treated for pulmonary aspergillosis in March and April 2002, which involved 8 weeks of intensive care at the veterinary hospital (NZP, Medical Record, Accession #214083). On August 14, 2002, the animal was taken to the Veterinary Hospital for treatment of aspergillosis, including nebulization, administration of fluids, and force–feeding of a nude mouse containing steroid medication (NZP, Pathology Report, Accession #214083). On August 15, the kingfisher was found dead at the Veterinary Hospital; the pathology report indicated that the animal was found with his head caught in a plant on August 10 and was monitored over the next 2 days. Other than a prescription for itraconazole and clotrimazole, there are no clinical notes in the medical record from June 6, 2002, to August 15, 2002, when a note indicated that the animal was removed from the collection (NZP, Medical Record, Accession #214083). Necropsy revealed that the animal died from necrotizing myocarditis caused by the West Nile virus. The heart, spleen, kidney, and brain were found to be positive for West Nile virus (NZP, Pathology Report, Accession #214083). The medical records and laboratory work were reviewed from 1998 with the pathology report. This animal died from cardiac lesions caused by the West Nile virus. The nude mouse body found lodged in the anterior esophagus of the animal was not noted as a cause of death in the pathology report (NZP, Pathology Report, Accession #214083). The force-feeding of mouse pups is considered an appropriate procedure for delivery of medication to a kingfisher in the judgment of the committee. Pygmy Hippopotamus - Accession #29218 This geriatric animal had a year-long history of stiff gait and intermittent anorexia. An examination done under anesthesia on October 1, 1999, revealed severe renal failure, and the animal was euthanized (NZP, Medical Record, Accession #29218). Necropsy revealed polycystic kidney disease. The animal was the sixth pygmy hippopotamus to die with polycystic kidney disease; five of the six were related, and further investigative work was initiated to understand this disease in pygmy hippopotamuses better (NZP, Pathology Report, Accession #29218). It is the committee’s judgment that the veterinary care provided this animal was appropriate and euthanasia warranted. Giant Panda - Accession #100357 This giant panda, 28 years 7 months old, had a long history of chronic renal failure, bridging spondylosis of the thoracolumbar vertebrae with mineralization of intervertebral disks, and degenerative osteoarthritis of the left elbow and carpus. Chronic epistaxis, decreased exercise tolerance, and keratitis with corneal ulceration had reduced the quality of this animal’s life until zoo keepers and veterinary staff agreed on euthanasia (NZP, Medical Record, Accession #100357). At necropsy, there was severe nephrosclerosis with focal interstitial nephritis, cardiomegaly with myocardial fibrosis, degenerative osteoarthritis involving multiple joints, and thrombosis of ecstatic vessels of the nasal turbinates (NZP, Pathology Report, Accession #100357). This geriatric giant panda had a number of age-related diseases that were diagnosed and treated in an acceptable manner before it was appropriately euthanized. Kodiak Bear - Accession #101108 This 27-year-old animal was euthanized on May 10, 2002, because of electroretinographically proven blindness (no electric activity when tested under anesthesia on September 24, 2001), skin wounds, and liver cancer (NZP, Medical Record, Accession #101108). At autopsy, a hepatocellular carcinoma with wide metastatic disease was found, in addition to the eye lesions and multiple other geriatric and complicating illnesses (NZP, Pathology Report, Accession #101108). It is the judgment of this committee that the veterinary care provided this terminally ill animal was acceptable, and euthanasia appropriate and warranted. California Sea Lion - Accession #102584

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Animal Care and Management at the National Zoo: Final Report This geriatric animal had suffered from cough for 2 months and was treated with a variety of drugs to combat suspected bacterial and fungal infections but continued to decline and have difficulty in breathing (NZP, Medical Record, Accession #102584). Euthanasia was performed on November 14, 2003, because of worsening of chronic respiratory distress despite prolonged treatment (NZP, Request for Specimen Euthanasia, Accession #102584). Necropsy suggested that laryngeal dysfunction caused the animal’s respiratory distress (NZP, Pathology Report, Accession #102584). It is the judgment of this committee that the veterinary care provided this animal was acceptable, and that euthanasia was appropriate and warranted for this geriatric animal because of the clinical findings. California Sea Lion - Accession #102590 This female sea lion was euthanized on February 2, 2001, because of severe liver disease. At autopsy, severe cholestasis, jaundice, renal bile casts, and a variety of unsuspected other abnormalities were found; the animal was also geriatric (NZP, Pathology Report, Accession #102590). It had become acutely anorexic. Diagnostics revealed severe hyperbilirubinemia, pointing to a major hepatic problem (NZP, Medical Record, Accession #102590). It is the judgment of this committee that the veterinary care provided this geriatric animal was acceptable, and euthanasia was appropriate and warranted. Orangutan hybrid - Accession #105170 This male orangutan was euthanized at the age of 14 years on October 18, 1999, because of recurrent severe air sacculitis (Pseudomonas) that had existed for 2.5 years. The animal was born in 1983, and numerous clinical-chemistry and hematology findings are recorded, but several anesthesia records are not included. On May 22, 1995, he was noted to have wounds on the neck and arm that healed well. Digital wounds were cast, but he was bitten again by Azy (another male) on July 31 and sustained severe local tissue damage. Antibiotics and other medications were given, and many immobilizations followed the injuries. Annual examinations, tuberculosis tests, and vaccinations are all well recorded. In 1996, a cough was noted, and air sacculitis was suspected. Pseudomonas was cultured and antibiotics were administered. In March 1997, bronchoscopy revealed much suppurative exudate in the airways. Medications were poorly accepted. Many antibiotics were administered, and nebulization was tried to get drugs to the air sacs, but all failed to stop progression of the bacterial air sacculitis. There was extensive documentation of veterinary care, and the keeper records are abundant (NZP, Medical Record, Accession #10170). Despite extensive therapeutic attempts to resolve the lung and air sac problems caused by Pseudomonas, the animal’s condition deteriorated, and euthanasia was performed (NZP, Request for Specimen Euthanasia, Accession #105170). At necropsy, the clinical diagnosis was confirmed as bronchopneumonia, and a pulmonary abscess was found (NZP, Pathology Report, Accession #105170). It is the committee’s judgment that the veterinary care provided this animal was acceptable, and the euthanasia appropriate and warranted. There is an issue with the husbandry provided this animal. The animal received multiple injuries from other hostile orangutans, and it is unclear to the committee why the animal continued to be exposed to them. Gorilla - Accession #107566 This animal was obtained from another institution and was in the care of the National Zoo for 13 years. Recurrent problems were periodontal disease, minor wounds and abscesses as a result of fighting among cagemates, otitis externa, arthritis, and overweight. Wounds were treated as needed, and she received regular dental treatments. The arthritis was treated chronically with NSAIDs and chondroprotectants. In 1998, variable intermittent changes in weight, appetite, and mobility were noted. An examination on February 24, 1999, indicated increased liver enzymes and an abnormal liver structure on ultrasonography. A liver biopsy was not done, because of the inability to check clotting times and the risk of blood loss in case of increased vascularity. The changes in the liver of this animal were considered chronic although the animal’s liver enzymes were normal 4 months earlier (NZP, Medical Record, Accession #107566). An examination on February 25, 2000, indicated severe periodontal disease, increased heart size with a soft murmur, spondylosis, abnormal liver structure, and two large fluid-filled structures in the abdomen on ultrasonography. In late March 2000, the animal was observed to have periods of lying down more often and to be less responsive or more depressed, and she was reported to be weak with noticeable tremors and increased respiratory rate on some days. Tachypnea, possible ascites, and occasional light-colored stools were reported on April 5, 2000. On April 9, the animal was recumbent with dyspnea and a distended abdomen and was unable or unwilling to rise. Physical examination revealed a loud systolic murmur, fever, and possible pulmonary edema, ascites, and hepatomegaly. Blood work revealed anemia, increased white-cell count, and increased bilirubin.

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Animal Care and Management at the National Zoo: Final Report Regurgitation of gastric contents revealed a large amount of blood. She appeared to improve until April 13, 2000, when she fell, cut her leg, was unable to rise, and appeared disoriented. The decision was made to euthanize the animal because of her moribund condition associated with advanced hepatic disease and right-sided heart failure (NZP, Medical Record, Accession #107566). Necropsy revealed a cholangiocarcinoma that had metastasized to regional lymph nodes, had irritated the pancreas resulting in a chronic focal pancreatitis, and had caused a chronic mild cholecystitis (NZP, Pathology Report, Accession #107566). Medical records and that pathology report were reviewed from April 3, 1987. Several outside experts (DVM, MD, and DDS) were consulted on numerous occasions in the latter years of this animal’s life. It is the judgment of the committee that the veterinary care provided this animal was acceptable and that euthanasia was warranted. Cheetah - Accession #110842 This animal was euthanized on June 28, 1999, because of deteriorating condition and a poor prognosis after a 12-month history of renal failure (NZP, Pathology Report, Accession #110842; NZP, Medical Record, Accession #110842). It is the committee’s judgment that the veterinary care and husbandry provided to this animal were appropriate. However, no euthanasia-request form could be produced, although it was noted in the animal’s file that the curator failed to produce the form after repeated requests from the registrar (NZP, Murphy memo, July 25, 2001). Cheetah - Accession #113355 On November 27, 2002, this animal was reported as depressed and as having partial anorexia. Blood work revealed renal failure (NZP, Medical Record, Accession #113355). The animal’s condition worsened, and it was euthanized on December 5 because of deteriorating condition and poor quality of life (NZP, Request for Specimen Euthanasia, Accession #113355). Necropsy revealed chronic interstitial nephritis, which caused the renal failure (NZP, Pathology Report, Accession #113355). It is the committee’s judgment that the veterinary care provided this animal was acceptable, and euthanasia was appropriate and warranted. Sumatran Tiger - Accession #113442 This neonatal Sumatran tiger died on June 24, 1999, because of aspiration of amniotic fluid during a difficult delivery (NZP, Pathology Report, Accession #113442). It is the judgment of this committee that the veterinary care provided to this animal was appropriate. Persian Onager - Accession #104834 On July 16, 2000, this animal was reported to be drinking excessively and had passed blood by rectum, but it looked fine and was in good body condition. The animal was found dead on July 17 (NZP, Medical Record, Accession #104834). Necropsy revealed that the animal died from salmonellosis (to which equids are particularly susceptible). The necropsy report suggests (in a handwritten note at the bottom of a page) that the animal may have been infected by Salmonella that earlier had caused the death of a scimitar-horned oryx at the zoo, inasmuch as the onager had been transported in the same trailer as the oryx. The exhibit area had been sterilized, but the trailer had not been sterilized. However, no documentation that the trailer had failed to be sterilized was available other than the handwritten note in the necropsy report and the same allegation in a clinical note (NZP, Medical Record and Pathology Report, Accession #104834). It is the judgment of this committee that the veterinary care provided this animal was acceptable. Owing to a lack of adequate records, the committee could not ascertain whether the onager acquired Salmonella as a result of a failure of the husbandry staff to sterilize the trailer before the onager was transported. Grevy’s Zebra - Accession #110719 This animal was found dead on January 22, 2000. Necropsy revealed that the animal died from inanition and hypothermia (NZP, Pathology Report, Accession #110719). The failures of the keepers to provide hay ad libitum in accordance with established procedure, to post the diet of the animal, to report problems with heat lamps, and to bed the animal heavily and lock it into its stall (NZP, memo to CRC Union Steward, May 25, 2000; NZP, memo to CRC keeper, March 29, 2000a; NZP, memo to CRC keeper, Marcy 29, 2000b; NZP, memo to Deputy Director, December 7, 2000; NZP, memo to CRC keeper, February 9, 2001) all contributed to the death of the animal. Although veterinary care did not contribute to the death of this zebra in the committee’s judgment, the medical record raises concern as to whether the animal received adequate attention from the veterinary staff at the

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Animal Care and Management at the National Zoo: Final Report CRC. The animal was born in 1989 and arrived at the Rock Creek Park facility from the St. Louis Zoo in July 1992. During its stay at the Rock Creek Park facility, it had a history of chronic recurring laminitis and lameness that required repeated prednisone and diuretic treatment. During its stay there, it was vaccinated on a regular schedule for rabies, tetanus, and encephalitis. The final clinical entry in the medical record before the animal was transferred to the CRC was, “Annual hoof trim and dental should be adequate” (NZP, Medical Record, Accession #110719). After the animal’s transfer to the CRC, there are a series of clinical notes in the medical record from January 30 to February 21, 1998, to treat the animal with a steroid and diuretic for lameness and leg edema. Other than parasite screens in 1999, there are no additional medical entries for this animal until a notation on January 22, 2000, that the animal was found dead in its stall. There is no evidence in the medical record that the animal received annual vaccinations, hoof trims, or dental examinations. Further complicating the issue, at the time of this animal’s death, its medical record was being simultaneously maintained in three record systems. Some time after the animal’s death, the MedARKS record was updated by the addition of the clinical notes from January and February 1998, as evidenced by the differences in the animal’s MedARKS record between a printing on March 30, 2000, and on June 23, 2003. Burmese Brow-antlered (Eld’s) deer - Accession #111413 On March 10, 2001, this animal was attacked by a pack of dogs and suffered lameness in the front and rear legs. The lameness in the left rear leg failed to resolve, and the animal was examined twice under anesthesia—March 19, 2001, when annual vaccinations were also administered, and March 29, 2001. A ruptured ligament was suspected, and surgery was performed April 20, 2001. The clinical-note entry for that date indicates that during intubation, the animal had a strong laryngeal reflex and chewing movements that severed the intubation tube. A tracheotomy was performed to retrieve the intubation tube from the trachea. The clinical note indicates that the animal was reintubated and surgery continued. However, in the rest of the clinical note, there is no mention of what surgical procedure was performed; in fact, the rest of the clinical note is identical to the clinical note of March 19, which details a physical examination, radiographs, and vaccinations that were performed. Therefore, it is unclear what, if any, surgical procedure was performed on the animal’s left rear leg (NZP, Medical Record, Accession #111413). After the surgery on April 20, 2001, there are no clinical notes until May 2, 2001, when the animal was anesthetized for an examination and radiography. The animal had surgery again on May 10, 2001, to repair the anterior cruciate ligament. The clinical note suggests that the animal’s joint had been clamped with nylon strands during the previous surgery on April 20, 2001, and that the radiographs on May 2, 2001 showed misalignment of the clamps. However, neither the April 20, 2001 nor the May 2, 2001 clinical entry reflects this information. During the surgery on May 10, 2001, the clamping on the joint was modified, and it was noted that the posterior cruciate ligament was ruptured. Screws were used to attach a tendon graft taken from the patella to the cruciate attachment of the femur. External fixation of the joint was placed with the use of pins placed in the femur and the tibia. After the surgery, there are no clinical entries from May 11, 2001 to May 17, 2001 (NZP, Medical Record, Accession #111413). On May 18, 2001, the animal was observed with one of the external fixation pins removed from the leg and bent. The animal was anesthetized to replace the external fixation pins, and radiographs were taken to confirm that the patellar graft and joint clamping were sound. After the surgery, there are no clinical entries from May 19, 2001 to May 28, 2001 (NZP, Medical Record, Accession #111413). On May 29, 2001, the clinical entry reflects that the animal did not want to get up on May 28, 2001. The animal did stand on May 29, 2001, but swelling was noted in the leg, and palpation revealed a fracture. The animal was anesthetized, and the bone was set and stabilized with pins. The next clinical entry, on June 1, 2001, notes that drug therapy was continued and that food consumption was minimal. An entry on June 6 indicated that the drug regimen was modified, and an entry on June 10, 2001 indicated that the pins had broken through the skin and were exposed about 0.5 inches; the wound was cleaned and the medications were to be continued. On June 12, 2001, the animal was unable to rise owing to a refracture of the femur. Euthanasia was performed (NZP, Medical Record, Accession #111413). This animal was euthanized because of multiple leg injuries that resulted from the attack by a pack of dogs, and it is the committee’s judgment that euthanasia was medically justified. However, the medical record raises concern because there were no clinical entries in the medical record after each surgical procedure until the next clinical problem arose, so it is not clear whether the animal was observed postoperatively. In addition, the medical entry that was made on April 20, 2001, is unacceptable, in that it fails to document the surgical procedure that was performed and indicates that the animal received vaccinations that had already been administered in the previous month.

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Animal Care and Management at the National Zoo: Final Report Burmese Brow-antlered (Eld’s) Deer - Accession #113296 A 12-year-old Eld’s deer was found dead, due to an apparent dog attack on March 10, 2001 (NZP, Pathology Report and CRC Veterinary Clinician’s Pathology Questionnaire, Accession #113296). The medical record was reviewed from April 1998 until the animal’s death. It is the judgment of this committee that the veterinary care provided this animal was acceptable. Scimitar-horned Oryx - Accession #104710 This animal was euthanized on April 21, 1999, due to advanced age, chronic lameness, and poor prognosis (NZP, Request for Specimen Euthanasia, Accession #104710). It is the committee’s judgment that the veterinary care provided this animal was acceptable, and euthanasia was appropriate and warranted. Przewalski’s Horse - Accession #105791 This horse was first noted to have a nasal discharge and poor body condition on December 14, 1999, and it was extensively worked up and treated over the next 8 months, including multiple endoscopy of the trachea, rhinoscopies of the nasal cavities, and radiography of the head. The animal was diagnosed with an intestinal parasite (treated with antihelmintics) and rhinitis and sinusitis (treated with multiple antibiotics through the middle of June 2000). The infection in the nasal cavity improved intermittently but was not resolved. On August 31, 1999, the animal was noted to have audible upper respiratory noises and continued poor body condition. The animal was started on antibiotics again but was not consuming all of its medicated feed. On September 5, the animal was observed to have a ruptured mass on the left maxilla. A physical examination under anesthesia and consultation with a local equine practitioner were planned for the next day, but the horse was found dead the next morning (NZP, Medical Record, Accession #105791). Necropsy determined that the animal died of sepsis (an infection and toxins spread via the blood) caused by a chronic Streptococcus zooepidemicus infection of the left guttural pouch. S. zooepidemicus was also cultured from the lung and heart (NZP, Pathology Report, Accession #105791). Medical records were reviewed for January 1, 1984, to death. A guttural pouch endoscopy was considered twice in January 1999 to rule out infection, but it was not performed because the animal’s sinuses and guttural pouches appeared normal on radiographs. In the committee’s judgment, the decision not to perform a guttural pouch endoscopy was acceptable based on the diagnostics performed. Przewalski’s Horse - Accession #106006 This animal was treated for lameness in May and June 1995. In August and September 1999, the animal was treated again for lameness with multiple drug therapies and corrective shoeing. In September 1999, radiographs showed severe laminitis (inflammation of lamella covering the last digital bone in the hoof). The prognosis was poor, and euthanasia was elected (NZP, Animal Health Patient Records, Accession #106006; NZP, Pathology Report, Accession #106006). Medical records were reviewed for June 28, 1995, to death. The medical record appears to be complete; there is a continuous record from 1984 until the animal’s death. However, numerous entries in the specimen record (NZP, Specimen Record, Accession #106006) of medical observations and vaccinations do not appear in the medical record. Evaluation of the specimen record and medical record in conjunction makes it appear that preventive medicine and veterinary care were acceptable in the committee’s judgment. However, the incompleteness of the medical record is unacceptable. Oryx Dammah - Accession #106054 This animal was anesthetized on September 13, 2002, for a general examination, blood work, and radiography of the left stifle, pelvis, femur, and sacral vertebrae because of difficulty in standing. The suspected hindquarter injury was a ruptured femoral head ligament. After good recovery from anesthesia, the oryx was housed in a bedded and padded stall and was later noted to be standing and interested in food. The medical record notes that the animal charged and hit the door with its head and the base of its horns; however, the animal’s condition after hitting the door is unclear. The animal was found dead on September 14 (NZP, Medical Record, Accession #106054). The necropsy was unable to identify the cause of death (NZP, Pathology Report, Accession #10654). The medical records were reviewed for August 4, 1984, to death. There is a continuous medical record from 1984 until the animal’s death with no obvious gaps; however, numerous entries in the specimen record (NZP, Specimen Record, Accession #106054) of medical observations and vaccinations do not appear in the medical record. Evaluation of the specimen record and medical record in conjunction makes it appear that the veterinary care

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Animal Care and Management at the National Zoo: Final Report provided the animal was acceptable in the committee’s judgment. However, the incompleteness of the medical record is unacceptable. Oryx Leucoryx - Accession #107973 This animal was euthanized on July 15, 1999, after a 3-month history of severe lameness in the left hind leg. The animal had an ossifying hematoma on the left stifle (the joint roughly equivalent to the human knee), which impaired walking. The animal was in poor body condition and lagged behind the herd (NZP, Medical Record, Accession #107973). The stifle lesion was most likely the result of an injury that had not healed normally because of the constant motion in the joint (NZP, Pathology Report, Accession #107973). The Specimen Record was reviewed from the animal’s arrival at the National Zoo on February 18, 1988, until it was euthanized in July 1999. Medical records were provided by the zoo only from June 10, 1999 to the date of euthanasia. It is the committee’s judgment that the veterinary care provided this animal during this short period was acceptable. However, there is no indication in the medical record or Specimen Record that the animal received any veterinary care, physical examinations, or preventive medicine between February 28, 1988, and June 10, 1999. The animal was appropriately euthanized because of her deteriorating quality of life; however, it is unclear, owing to the failure to keep appropriate medical records, that she was receiving appropriate husbandry or medical care before June 1999. Because of the incompleteness of the medical record, the committee was not able to assess whether inadequate veterinary care contributed to the animal’s death. Oryx Leucoryx - Accession #108300 On July 15, 2001, this oryx was housed with a female herdmate, and both were fasted for a preshipping examination the next day (NZP, Pathology Report, Accession #108300). Overnight, the oryx was gored in the left side several times by the herdmate (NZP, Medical Record, Accession #108300). During anesthesia induction for transport to the veterinary hospital, the animal thrashed several times, a substantial amount of dirt lodged in its mouth. Attempts to clean the mouth of dirt were unsuccessful before intubation was necessary. The animal’s wounds were cleaned, and drains were placed to promote wound drainage. The animal was maintained at the hospital on antibiotic therapy for 3 days. On July 19, 2001, the oryx had an increased respiratory rate and appeared depressed and unsteady when standing. She was anesthetized the next day for the drain removal. During anesthesia, xrays were taken and showed that the animal had pneumonia. The animal suffered cardiac arrest and died while under anesthesia (NZP, Medical Record, Accession # 108300). The pathology report determined the cause of death to be cardiac arrest while under anesthesia complicated by aspiration pneumonia and glomerulonephritis (NZP, Pathology Report, Accession #108300). The medical records for May 10, 2000, to death were reviewed. Preventive vaccinations and husbandry care appear to have been adequate in the period reviewed. The zoo did not provide medical records prior to May 2000, and the specimen record (NZP, Specimen Record, Accession #108300) reflects only one medical observation and no vaccinations from the time the animal was released from quarantine on arrival in fall 1988 until May 10, 2000. Therefore, the committee was unable to assess the veterinary care and preventive medicine provided the animal during this 12-year period. The pathology report indicated that the animal had been azotemic since May 2001; however, the medical record available to the committee contains no record of blood work or mention of this condition. In the committee’s judgment, the aspiration of dirt during the sedation of the animal was not caused by failure of the veterinary staff to administer anesthesia properly; sedation of wild animals can be difficult even for well-trained and experienced veterinarians. However, the committee was unable to assess veterinary care before the incident because of recordkeeping deficiencies. Oryx Leucoryx - Accession #109698 This animal was euthanized on July 24, 2001, after a 6-day history of lameness. The timeline of events for this animal is unclear in that the entries in the medical record contradict one another. Clinical notes entered in the medical record indicate that an examination was performed under anesthesia on July 16, 2001; that the animal developed an abnormal gait on July 19, 2001; and that it was found down and unable to get up on July 20, 2001, at which time steroids and the NSAID Ketofan were administered. However, the July 20, 2001 clinical entry contains a comment that the animal was anesthetized on July 15, 2001, displayed an abnormal gait on July 16, 2001, and was found down and unable to stand on July 17, 2001. The comment further states that steroid therapy was initiated for 36 hours but that the animal showed no improvement. No prescription for steroid therapy is entered into the medical record until July 20 (NZP, Medical Record, Accession #109698). Further complicating the events, the Specimen Record indicates that the animal was anesthetized on July 16, 2001, was observed lame on July 17, 2001, and was unable to stand and had steroids and Ketofan administered on July 18, 2001 (NZP, Specimen Record, Accession

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Animal Care and Management at the National Zoo: Final Report #109698). Over the next 3 days, the animal was still unable to stand and because of its deteriorating condition was euthanized on July 24, 2001 (NZP, Medical Record, Accession #109698). The medical record contained no entries from December 1990 (5 months after birth) to May 2000 (14 months before death). However, the specimen record (which is compiled from input from the veterinary and nutritionist staff as well as input from the assistant curators regarding behavioral observations and husbandry procedures performed by keepers) documents that the animal was treated by veterinary staff in March and September 1991, but that no further interaction with the veterinary staff occurred until May 2000. The specimen record entries in March and Spetember 1991 reveal deficiencies in the veterinary record and indicate to the committee that the specimen record does reflect the care provided to this animal. In the committee’s judgment, veterinary care provided the animal from 1992 to 2000 was unacceptable owing to the lack of veterinary observation or vaccination. However, the animal was appropriately euthanized, inasmuch as its condition was deteriorating because of the inability to rise. The cause of the animal’s clinical symptoms is unknown to the committee because the pathology report provided by the zoo was incomplete and did not contain final diagnoses or a cause of death (NZP, Medical Record, Accession #109698). Scimitar-horned Oryx- Accession #110177 This animal was found dead on November 23, 2001, owing to multiple liver abscesses (NZP, Pathology Report, Accession #110177). A slight lameness had been reported that resolved about 4 months before the animal was found dead. The animal was weighed at that time, and no weight loss was evident (NZP, Medical Record, Accession #110177). The pathology report states the animal was in good nutritional condition (NZP, Pathology Report, Accession #110177). It is the judgment of this committee that the veterinary care provided this animal was appropriate. Scimitar-horned Oryx - Accession #110612 This female scimitar-horned oryx was known to be pregnant and approaching her delivery date. She separated from the herd on July 17, 1999, and was observed to be straining on July 20, 1999. When checked at 8:00 p.m. on July 20, the oryx was reported “up moving around, didn’t appear to be in too much discomfort.” Blood was observed on her rear legs. She was found dead the next morning (NZP, Pathology Report, Accession #110612). The pathology report indicated that death was due to dystocia caused by a malpositioned large male fetus. Dystocia resulted in a uterine rupture and extensive hemorrhage “suggestive of a prolonged dystocia event” (NZP, Pathology Report, Accession #110612). In the committee’s judgment, this animal, which is extinct in the wild and was part of an artificial-insemination project, should have been observed throughout the night or until a successful delivery had been achieved. However, the committee acknowledges that even with observation, this animal may not have survived. The veterinary and animal care staff at the zoo should have an established protocol for pregnant females as their delivery date approaches and the first stages of labor are observed. Przewalski’s Horse - Accession #110627 This animal was found dead on July 23, 2000, owing to a lightening strike (NZP, Pathology Report, Accession #110627). The medical record was reviewed for May 1992 to death. In the committee’s judgment, the veterinary care provided this animal was acceptable. Arabian Oryx - Accession #111021 In February 2000, this animal was treated for a gore wound and was noted to have a poor body condition. Over the next 17 months, the animal continued to lose weight and developed chronic parasitism that was unresponsive to treatment. It eventually developed persistent high fibrinogen and low serum calcium (NZP, Medical Record, Accession #111021). The animal was euthanized on July 16, 2001, because of deteriorating condition and poor quality of life (NZP, Request for Specimen Euthanasia, Accession #111021). Necropsy revealed chronic renal failure and renal secondary hyperparathyroidism (NZP, Pathology Report, Accession #111021). It is the committee’s judgment that the veterinary care provided this animal before euthanasia was acceptable. However, the medical record contains no entries from August 1996 until it was gored in February 2000, However, the specimen record (which is compiled from input from the veterinary and nutritionist staff as well as input from the assistant curators regarding behavioral observations and husbandry procedures performed by keepers) documents that a routine fecal check was performed in 1999. The specimen record entry in 1999 indicates to the committee that the specimen record does reflect the care provided to this animal.

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Animal Care and Management at the National Zoo: Final Report In the committee’s judgment, veterinary care provided the animal from 1992-2000 was unacceptable owing to the lack of veterinary observation or vaccination, but that failures in veterinary care did not contribute to this death. In addition, the euthanasia form was incomplete. SUMMARY After evaluating the care provided 48 animals that died since 1999 at the Rock Creek Park or CRC facility, the committee concludes that in the majority of cases, the animals received appropriate care throughout their life at the National Zoo. In a minority of cases, the committee found evidence of apparent inadequate care or recordkeeping deficiencies. The recordkeeping deficiencies made it difficult to determine whether husbandry and veterinary procedures occurred but were not documented or whether the procedures were not performed. Due to this ambiguity, the committee could not definitively identify the factors that caused or contributed to an animal’s death. In reviewing the many publicized animal deaths at the Rock Creek Park facility, the committee found some instances of inadequate care; however, the committee’s evaluation of randomly selected, unpublicized megavertebrate deaths at the Rock Creek Park facility revealed the animals were generally well cared for and their care was documented, suggesting that the publicized animal deaths were not indicative of a wider, undiscovered problem with animal care at the Rock Creek Park facility. At the CRC facility, few animal deaths reached the public’s attention; however, the committee’s evaluation of animal deaths revealed problems with veterinary recordkeeping and potential problems with the preventive medicine program on a scale that is similar to those previously documented at the Rock Creek Park facility. In reviewing all of the failures identified in its review of recent animal deaths at the National Zoo, the committee identified a single organizational issue that created an environment where these events could occur. The lack of open communication and collaboration among keepers, curators, veterinarians, nutritionists, and senior management was evident in almost every case where inadequate animal care was evident. This deficiency is more obvious in some instances, such as the death of the Grevy’s zebra at the Rock Creek Park facility, where the animal’s diet was changed multiple times without the involvement of the nutritionist. However, even in the cases where failures occurred within a single department, such as the widespread failures of the veterinary staff to provide adequate preventive medical care to the animal collection, it is unclear why the keeper and curator staff did not object when animals in their care failed to receive the appropriate preventive medical care, and why senior management did not act to bring in temporary or permanent staff to address the staffing problems in the veterinary department that contributed to this problem. The committee observed that the individual departments of the zoo, even though they are all supporting the same animal collection, seldom worked collaboratively. This practice disrupts the system of checks and balances, allowing failures in animal care to occur repeatedly. Regular communication and collaboration on all aspects of animal management can mitigate human errors, which are bound to occur within any organization. Because multiple people are actively involved in the care of each animal, it is less likely that inadequate care will go unnoticed. Developing a team approach to animal care is particularly important at a facility like the National Zoo, whose animal collection as a whole is geriatric and requires additional consideration. While effective collaboration and communication among keepers, curators, and veterinary nutrition staff is essential, it is important that the veterinary staff understand they have the ultimate responsibility for medical decisions regarding the animal collection. Senior management must ensure that the veterinary staff has the authority to ensure the provision of adequate veterinary care to both the exhibit and the research animals and to oversee the adequacy of other aspects of animal care and use, as required by the Animal Welfare Act (9CFR 2.33 and 2.40). Considering the long-standing nature of the communication problems at the zoo and the protective mindset and defensive environment this situation has created, it will take time and much effort to reverse completely the closed and negative organizational culture that currently exists at the zoo. It is important that the activities and operations of the National Zoo remain open to the zoo community and the public through the publication of papers by zoo scientists, unannounced inspections by the US Department of Agriculture, and collaborative projects with other zoos, as this will provide an external pressure on the zoo to continue in the direction of positive change. FINDINGS AND RECOMMENDATIONS Findings: A scientific evaluation of the care provided 48 animals that died since 1999 at the Rock Creek Park or CRC facility reveals that in the majority of cases, the animals received appropriate care throughout

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Animal Care and Management at the National Zoo: Final Report their life at the National Zoo. In a minority of cases, the committee found evidence of inadequate care or lapses in recordkeeping. The lapses in recordkeeping made it difficult to determine whether husbandry and veterinary procedures occurred but were not documented or whether the procedures were not performed. Recommendations: The zoo must take immediate steps to clarify the actions, procedures, and observations that must be included in each type of record created by animal-care, veterinary, and nutrition staff. The apparent inadequate care caused by failures on the part of the veterinary, nutrition, and animal-care staff at the Rock Creek Park facility are being addressed by recent changes in policies and new initiatives by the zoo. The zoo should continue efforts to establish accountability for unprofessional actions that involved any level of staff. This evaluation of recent deaths at the CRC facility reveals widespread veterinary recordkeeping deficiencies, raising concerns about the adequacy of the preventive medicine program at the CRC. Senior management should evaluate whether the veterinary staff was adhering to the preventive medicine program from 1999 until recently and continue its current efforts to establish oversight and accountability for the veterinary staff at the CRC.