| Complaint: | Complaint 21-71 |
|---|---|
| Respondent: | Rachel Liepman |
| Premises: | Chaparral Veterinary Medical Center |
| Related: | 21-72, 21-73 |
The complainant, a doctor, says that their three year old horse began experiencing symptoms of colic. Their veterinarian, Bryan Nolte (repeat respondent in veterinary board complaints and part of Prescott Animal Hospital and Equine Center, a facility with close ties to the ever-present Dow veterinary dynasty and father-and-son Board investigators), said the horse needed to get to a surgeon. He suggested Chaparral as one of the options; their horse trainer, Roberto, took the horse there. Liepman, one of the veterinarians at Chaparral, allegedly examined the horse and said that the horse would likely progress to needing surgery; there were four or five horses already in line for surgery but they eventually got around to it. The complainant says they were told the surgery went well; they later learned that the surgeon had consulted with the practice owner about the surgery but that this entry was never put in the medical records. The recovery was said to be uneventful but the complainant's wife, also a doctor, visited the horse and said he wasn't his usual self; she noticed the horse wasn't eating and his urine seemed concentrated; the horse was apparently treated with some different medications and sedatives and also broke out in hives. Liepman wasn't around at the time but later called and said the horse was doing well and could come home.
The complainant and Roberto came to get the horse; the complainant said he noticed nothing unusual but Roberto noted some concerns after the fact. About 45 minutes down the road Roberto noticed blood on the side of the trailer in his rearview mirror. They pulled over, went back, and found the horse dead from what the complainant describes as "wound dehiscence with evisceration of bowel and omentum," also noting "the startling thing was the amount of blood." The complainant (again, a doctor) says that he's seen many dehiscence and evisceration scenarios at his day job and that one this messy is usually the result of "some major catastrophic vascular event." He states that the ride itself was uneventful with no obvious thrashing in the back, and he also notes that Roberto is a well known horse trainer who has moved horses literally thousands of times. He called Chaparral immediately from the side of the road; veterinarians Liepman and Moyer offered their condolences and offered him refunds on any remaining horse medication that would now go unused. He didn't know what to do with the body so he called Nolte (the horse guy from Prescott Animal Hospital) who suggested burying the horse at a barn or taking the corpse to the landfill. The horse was eventually buried with a backhoe. The complainant notes that he and his wife weren't thinking clearly at the time given their bonds with the horse but wonder why Chaparral didn't want the horse brought back for a necropsy.
His wife subsequently talked to Andrea, the practice owner, who said that an internal review found no fault on their part; when the complainant's wife said she didn't feel they should have to pay for the surgery we're told that Andrea got angry and said that the complainants were only interested in money. Andrea said the horse must have died from a hard fall in the trailer. Several days later, David Stoll (frequent defender of veterinarians before the board in conjunction with colleague W. Reed Campbell) asked to speak to the complainant's wife; he offered her $3500 but she turned him down. The complainant and his wife instead wanted to get their horse's medical records but failed to do so until several efforts and hiring an attorney of their own. He believes that the horse likely had an undiagnosed vascular injury that popped when the horse got up into the trailer with the horse bleeding out from the inside and finally bled out all over the place; he also speculates that the root cause was an unexperienced and overworked junior veterinarian combined with inadequate follow-up care.
Liepman says that in addition to the initial exam of the horse she was also repeatedly told the horse suffered from narcolepsy (this is setting us up for one of the alternative explanations, namely that the horse passed out, popped open, and bled out all over the place). She initially believed that the horse could be treated with medical management but the horse suffered from pain; at that point she conferred with Andrea (boarded vet surgeon) and Moyer (boarded vet surgeon) who still recommended medical management if things didn't get worse. However, things got worse, and that was when it was time to cut; the surgery was uneventful and no intestine was removed while fixing the 720-degree colon volvulus. The horse was monitored for five days as his condition improved and so the horse was subsequently discharged; she says both the complainant and Roberto had no concerns with the horse and even examined the incision. She also reports the horse had several more bouts of narcolepsy while at the hospital. She reiterates that the surgery was done by Moyer, a board-certified large animal surgeon and attended to by none other than herself, a boarded internal medicine specialist. She also says that up until the horse died the complainants spoke to her and said she was doing a good job. She says the consultation the complainant refers to was only done because they need to figure out what surgeon could do the operation, nothing sinister was involved. She also says that the complainant's idea of what happened with the horse rupturing and bleeding out is impossible for a horse; she says he's blinded by his notions of what's possible in human medicine but that he's never treated something as big as a horse. She also says that she was never asked what to do with the body but if asked they could certainly have taken a look to see what happened, as could Nolte, the regular horse veterinarian. We're also told that in any event the complainant signed a form saying that whatever happens to the horse after discharge is his responsibility, not theirs. She also takes exception at him calling anyone there inexperienced as they're all board-certified veterinarian in surgery or internal medicine (in veterinary board complaints it appears that professionals in human medicine often find the conduct of professionals in veterinary medicine somewhat less than what they're used to).
The Investigative Committee said that we'll never know what happened (not unlike what they said about another horse at Chaparral in 19-24) but all the care provided was good. The Committee felt that internal bleeding couldn't have caused what was seen; they say "based on the pictures of the amount of blood, the blood splatter, and blood on the side walls of the trailer" that the horse instead died from an "acute event." Much like Leipman and friends, they helpfully suggest that the horse passed out and popped open; they also suggest that perhaps Roberto drove too fast or hit the brakes, causing the horse to fall down and pop open with his guts all over. (If the horse bled out because the horse fell down and the surgical site popped open, does that make the veterinarians who sent him home look any better than if the horse bled internally until he popped open instead?) They express puzzlement as to why nobody felt the horse fall down thrashing and kicking all over (the complainant's suggestion of the horse bleeding internally and then passing out from hypotension could explain that, but he's a doctor, not a veterinarian).
A quick search of Google reviews about Chaparral leads to a rather poor review (one star) that mentions Liepman. MsSadams3 writes that her donkey needed a tracheotomy and Liepman hopped in rather than running an x-ray or ultrasound; according to the reviewer Liepman botched it and nailed her donkey's jugular vein instead, leading to the donkey dying in terror. Chaparral responded to the review and said that it must be difficult but they were trying to do the best with what they could at the time.
| Source: | June 6, 2021 AM Investigative Committee Meeting |
|---|---|
| People: | |
| David Stoll | Respondent Attorney |
| Rachel Liepman | Respondent |
| Roll Call: | |
| Carolyn Ratajack | Aye |
| Christina Tran | Absent |
| Jarrod Butler | Aye |
| Robert Kritsberg | Aye |
| Steve Seiler | Aye |
| Result: | Passed |
| Source: | July 7, 2021 Board Meeting |
|---|---|
| People: | |
| David Stoll | Respondent Attorney |
| Proposed By: | Robyn Jaynes |
| Seconded By: | Darren Wright |
| Roll Call: | |
| Darren Wright | Aye |
| J Greg Byrne | Absent |
| Jane Soloman | Aye |
| Jessica Creager | Aye |
| Jim Loughead | Aye |
| Nikki Frost | Aye |
| Robyn Jaynes | Aye |
| Sarah Heinrich | Absent |
| Result: | Passed |
The primary source for the above summary was obtained as a public record from the Arizona State Veterinary Medical Examining Board. You are welcome to review the original records and board meeting minutes by clicking the relevant links. While we endeavor to provide an accurate summary of the complaint, response, investigative reports and board actions, we encourage you to review the primary sources and come to your own conclusions. In some cases we have also been able to reach out to individuals with knowledge of specific complaints, and where possible that information will be included here.