Andy Roark DVM MS

Dr. Anna McManamey joins the podcast to discuss heart murmurs in cats. Alabaster is a 4 year old MN domestic shorthair who is in for his first dental cleaning. On physical examination, Alabaster has a grade 2-3/6 systolic murmur. Dr. Mac breaks down what her concerns are, the risk factors and next steps to take. Let’s get into it!

You can also listen to this episode on Apple Podcasts, Google Podcasts, Soundcloud, YouTube, or wherever you get your podcasts!

LINKS

Retain Your Team: Speak the Languages of Appreciation in Your Workplace – May 21, 2022: https://unchartedvet.com/product/appreciation-languages-101/

What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. McManamey (aka Dr. Mac) is a veterinary cardiologist. She received her degree of veterinary medicine from the University of Missouri. She then completed a rotating internship at the Ohio State University followed by an emergency and critical care internship at North Carolina State University. She finished her cardiology residency at North Carolina State University and became an ACVIM diplomate in 2021. Dr. Mac is currently an assistant clinical professor at Purdue University in Indiana. Cardiology is her favorite subject because it can be made as simple or as complex as needed. Furthermore, every animal has a heart and that means Dr. Mac gets to work with all kinds of species. Her areas of interest within cardiology are echocardiogram, congenital heart disease and interventional procedures, as well as emergency management of cardiac disease. She has a very supportive and patient husband along with three canine fur-children, one of which had a patent ductus arteriosus (of course).

EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:
Welcome everybody to The Cone of Shame veterinary podcast. I am your host, Dr. Andy Roark guys I got a great medical episode today with the one and only doctor Mac, Dr. Anna McManamey is on the podcast and she’s been on before. I met her, just, we just sat down next to each other at the VMX conference. And I started talking to her and she was delightful and awesome.

Dr. Andy Roark:
And I learned so much just sitting next to her. I was like, “You have to be on a podcast.” And this is her second appearance on the podcast. She is really great. You guys are going to get some great pearls in a short amount of time. We are talking about a four year old male neuter, domestic short hair who has a systolic murmur. Who’s in for a dental. What do you do with that? Do you do that case? Is that going to be okay? What precautions do we need to take? How concerned should we be. Guys you’ve seen this case. You don’t want to miss this. Let’s get into this episode.

Kelsey Beth Carpenter:
(singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to The Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:
Welcome to the podcast. Welcome back to the podcast, Dr. Mac. Thanks for being here.

Dr. Anna McManamey:
Thank you for having me.

Dr. Andy Roark:
Oh man. I enjoy having you on the podcast. I’m so glad you’re back. I have a, well, let me pause and introduce you to those who don’t know you are a professor of cardiology at Purdue’s College of Veterinary Medicine and a lecturer and a genuinely wonderful smart person and a great darn teacher. And so that’s why I hope that you would be able to help me out with this case.

Dr. Anna McManamey:
Happy to be here. It sounds so fancy when you say it that way.

Dr. Andy Roark:
I know. Yeah, I get introduced and people are, this is Andy and he has this big title and I’m like, that sounds really fancy

Dr. Anna McManamey:
I don’t know if I’m qualified. Yeah. Obvious.

Dr. Andy Roark:
I know. I’m like, boy, I hope they don’t ask me hard questions.

Dr. Anna McManamey:
Yeah. Yeah.

Dr. Andy Roark:
Because I can’t justify this.

Dr. Anna McManamey:
Yeah, I’m a newbie cardiologist, but I’m enthusiastic so.

Dr. Andy Roark:
No, you’re I think you’re amazing. I love having you on the podcast. I have a kitty cat that I need help with. I, and again, maybe this is just my personal bias maybe it’s just the ratio of dogs to cats that we tend to see in practice. Maybe it’s just sort of the secret of nature of cats. Maybe it’s that cats are a little bit harder to physically examine than dogs sometimes. I don’t feel like I find a lot of heart murmurs in cats relative to heart murmurs in dogs. But I got one, I have a four year old male neuter, domestic short hair named Alabaster who came in for a dental cleaning and he’s got a heart murmur. He’s got a grade two, maybe a grade three. I’m not the best at nailing. Exactly. He’s in the grade two, three range.

Dr. Andy Roark:
Yeah, just a systolic heart murmur. No complaints from the owners. He doesn’t seem to be coughing or anything. They said, I asked them, “Is he coughing?” And they’re like, “Not more than usual.” And so that usual, okay. Yeah. So it’s that?.Yeah. So I’m looking at this cat one is anesthesia patient, but then also number two is just a general maintenance of a fairly young cat that I had not heard a heart murmur in before. Dr Mac, how do you treat that? Where do you go with this case?

Dr. Anna McManamey:
Yeah, I think that’s a great question. This is a very common scenario of why a lot of cats come to see me honestly. I think you hit a lot of good points right off the bat. Cats are sneaky. Cats they hide their disease. They don’t usually act sick even when they are sick. And then there’s a very frustrating, I guess, ratio of the number of cats that have heart murmurs that actually have heart disease and vice versa. So when you hear a murmur in a cat, I’d say it’s a 50, 50 chance that they have structural heart disease. So still-

Dr. Andy Roark:
Okay.

Dr. Anna McManamey:
… a reasonable chance that they do have that structural heart disease that you need to further investigate before putting them under an anesthesia where they’re going to get fluids as part of their anesthetic protocol. So in cats, a murmur usually is from some type of outflow tract obstruction. So whether that’s like an HOCM, so hypertrophic obstructive cardiomyopathy. Or some type of less pathologic form, a dynamic right ventricular tract obstruction. But usually that’s where we see these murmurs in these younger cats, mitral valve disease really isn’t common in cats.

Dr. Anna McManamey:
It happens in really older cats like geriatric kind of cats. But in this young of an animal, I think it’s very appropriate. It’s a male cat, it’s a middle aged cat, domestic short hair. Those are animals that are predisposed to HCM and structural heart disease. So what are you going to do with it? Well, I think if this were a dog, the answer would be easy. Take a set of baseline chest X-rays, know what you’re dealing with. Unfortunately in cats because their heart disease, they get most commonly is a hypertrophic cardiomyopathy. It’s a concentric thickening of the ventricle. So the ventricle thickens inward. And so taking X-rays on a cat, their heart can look miraculously normal, even if they have significant disease. So I say that an X-ray is helpful for ruling out severe, severe heart disease, maybe. But honestly, if you see a big heart, they probably have heart disease. If you see a normal looking heart, they still could have heart disease.

Dr. Andy Roark:
So 50, 50 chance they could have like

Dr. Anna McManamey:
Yeah. It’s frustrating, right? Because you got this cat-

Dr. Andy Roark:
Yeah, that’s not-

Dr. Anna McManamey:
… you want to do the dental. It’s asymptomatic.

Dr. Andy Roark:
It’s much less helpful than I thought.

Dr. Anna McManamey:
Yeah. I know. So I still think X-rays are okay. I think that again, if you see a big heart on X-rays, then I’d say, well, you probably do have heart disease. If I see a normal heart on x-rays, it just doesn’t rule out heart disease. So X-rays not wrong to do the other thing that’s growing in popularity that I actually really like is something called the BNP. So it’s just a B-type natriuretic peptide. So this is a biomarker. It is very, very specific for the heart. And what it tells us is if the heart is stretched. So it doesn’t tell us what the heart disease is. It doesn’t matter if it’s even primary heart disease, it could be like in an older cat could be hyperthyroid heart disease, could be systemic hypertensive heart disease. But what it tells us is the ventricles are under some type of duress.

Dr. Anna McManamey:
They’re either having a pressure overload or a volume overload something’s going on. And this is a blood test. It’s usually always going to be sent out like IDEX is the one that owns this test currently. So it’s going to be a turnaround. So it’s not going to be same day results, but it’s a simple blood test. You can do it with their pre anesthetic blood work for example. It goes out the range for cats is pretty tight. It’s about zero to a hundred kind of picomole per decaliter is the range. And usually if it’s in that range, I don’t worry at all about any type of structural heart disease.

Dr. Anna McManamey:
If it’s outside that range, it’s a pretty sensitive test. So you might get cats that have false positives, meaning it’s a little bit outside the range, but their hearts look very normal echocardiographically, but that’s a good screening test. In my opinion, it’s better than maybe even X-rays just because again, you can have pretty severe heart disease, but a normal heart on X-rays. So the BNP, in my opinion is the cheat man’s echo. And if you can’t get to cardiologist right away, or you don’t have the money to get to a cardiologist, then a BNP is a very appropriate screening tool. And I’m looking for that number to be higher than a hundred.

Dr. Andy Roark:
Do you add that in as a routine screening test for patients you’re planning to put under anesthesia? Is it that level of screening tool utility or are you still thinking mostly patients have… I have questions or concerns about I add this on to. I’m just curious.

Dr. Anna McManamey:
Yeah. Yeah.

Dr. Andy Roark:
Are you just sending these out all day or is this a targeted?

Dr. Anna McManamey:
I know. This is a slippery slope. I’m definitely in the case.

Dr. Andy Roark:
You’re a cardiologist too. You’re like, “You’re asking the wrong guy, uh.”

Dr. Anna McManamey:
But I do. I think I realize that not everyone can come see me. Right. I mean, we see-

Dr. Andy Roark:
Sure, totally.

Dr. Anna McManamey:
It’s going to sound really bad when I tell you how many cases I see a day, it’s not enough, but I don’t have enough time to see all these cats. And so what are we going to do in the meantime? But I do think that the BNP in the cat, not so much the dog but in the cat, I think it’s appropriate to start screening cats, just like you do for hyperthyroidism.

Dr. Anna McManamey:
There’s enough cats that don’t have heart murmurs that have heart disease. And so wouldn’t it be nice if we could catch them earlier to just let the client know what’s going on with their pet, what they need to watch out for with their pet. Is there any medication their pet should be on before congestive heart failure or something happens? So I might make some people mad when I say that, but I do. I think it’s-

Dr. Andy Roark:
No, no.

Dr. Anna McManamey:
I think it’s a good enough test that it might be worth doing more often.

Dr. Andy Roark:
I mean, at what age do you start to think about screening for things like this? Right? Because it is a measurement of sort of the state of the heart.

Dr. Anna McManamey:
Yeah.

Dr. Andy Roark:
So it seems like screening kittens is probably not going to be super productive or really insightful for the future. But I mean, are you talking about five year old cats? Are you talking about eight year olds? Is this a senior wellness type of screen in your mind?

Dr. Anna McManamey:
Yeah.

Dr. Andy Roark:
I’m just curious kind of, when you look in your crystal ball, kind of where do you see that going or how do you use that tool in your toolbox?

Dr. Anna McManamey:
Yeah, first of all, highly recommend a crystal ball to every veterinarian because they do come in a very, very handy.

Dr. Andy Roark:
Well mine has been craptastic for the last three, four years. It’s just boy.

Dr. Anna McManamey:
God, I wish I had one of those. But, yeah, I think that’s a great question. So I would say if you look at HCM, hypertrophic cardiomyopathy as a model of heart disease, because it’s the most common heart disease we see in cats, it’s usually around five to eight years of age where that kind of takes its peak effect in cats. However, we see some cats as young as three. So I think five seems like a magic number for me.

Dr. Andy Roark:
Okay.

Dr. Anna McManamey:
I think maybe three is a little early, but you could catch some that are starting to show signs earlier, but I’d say it’s early as five, but I think kind of that eight years of age, when you’re starting to screen for hyperthyroidism, it’s probably appropriate to be doing the same for the heart.

Dr. Andy Roark:
All right guys, I want to jump in here with a couple quick updates. First of all, the uncharted veterinary conference was last week in a Greenville, South Carolina it was amazing. We will have a virtual conference in the back half of this year. It’ll be in October. It is our GSD for Get Stuff Done Shorthanded that’s right. Get Stuff Done Shorthanded is going to be a virtual conference, which means you can join it anywhere. It will be in October more details coming soon. Registration is not yet open, but go ahead and get fired up. This is a great way to see what Uncharted is all about. See is it really different from everything else like people say it is. Yeah, you can come and see just how that works online. And then if you love it, we’ll see you in person April next year in Greenville, South Carolina, or if you’re a practice owner, we’ll see you in person in December for our practice owner summit.

Dr. Andy Roark:
Gang, if you can’t wait that long and you know you can’t wait that long, we have a couple of workshops coming up. We have retained your team, speak the languages of appreciation in your workplace. That is with Dr. Tracy Sands. It is on May 21st. It is all about showing your team appreciation. You know they’re tired, you know they’re overwhelmed, you know that they want to feel appreciated for their work. Are you doing it right? Are you showing them appreciation? There are simple things that you can do that really make a difference. Guys, this is, as I said, May 21st, 2:00 PM Eastern, 11:00 AM Pacific time. It is $99 to the public. It is free for Uncharted members. Jump on a, get registered, come and be there. This one is actually already filling up. It’s a month away and the spots are largely taken. So jump in there and grab a spot while you can.

Dr. Andy Roark:
On June 8th, my friend, Bill Schroeder, founder and CEO of InTouch Veterinary Communications is doing his workshop, creating content that clients crave. This is all about making information in a way that clients will want to consume it. If you’re tired of trying to educate in the exam room, if you want some backup, if you want some help, if you’re like, I don’t have enough time to communicate everything, I need to communicate. Jump in on this webinar or it’s a workshop you’re actually going to work on the thing. That’s the difference in a workshop and a webinar. We do the thing and uncharted. June the 8th, 7:00 PM Eastern, 4:00 PM Pacific time. This is $99 to the public, free for Uncharted members. You can hit the link in the show notes and get registered for that as well. Guys, that’s enough for me. Let’s get back into this episode.

Dr. Andy Roark:
Talk to me a little bit about blood pressure in these cats. Is that going to be an insightful tool when I’ve got this sort of heart murmur? Yeah. I mean, is that something? It didn’t come immediately to hand, I guess when we talked about chest X-rays, when we talked about the BNP.

Dr. Anna McManamey:
Yeah.

Dr. Andy Roark:
Is there real value in trying to get this cat calmed down in a nice secluded place and try to get a good blood pressure and what can I gain from that?

Dr. Anna McManamey:
Yeah, that’s a great question. So I usually will reserve the blood pressure. I think it’s a very important test, but I usually will keep it for a little bit later in the lifespan of a cat. So it’s unlikely that the cat at this age at five years of age is going to have systemic hypertension. However-

Dr. Andy Roark:
Okay.

Dr. Anna McManamey:
… that’s a very cheap, very accessible test to do, because again, if your BNP is high, you’re kind of obligated to check a systemic blood pressure and to check a thyroid level. Again, even though it’s unlikely in a cat that young, if those two diseases are present, whether that’s systemic hypertension or hyperthyroidism, both of those conditions cause a thick left ventricle, would cause an elevated BNP. So definitely has its place again in that age range, I’d be less suspicious of it, but totally appropriate to do.

Dr. Andy Roark:
Okay. Let’s talk about management of heart disease in cats. And I think that’s something that probably compliance and adherence are often a bit of a challenge. It’s hard, especially if we have ongoing medications for these cats. How do you introduce the idea of long term medication to pet owners? What sort of pearls of advice do you have for setting pet owners for success?

Dr. Anna McManamey:
Yeah, it’s a great question. And I think with cats, it’s just a whole nother level of difficulty than compared to dogs.

Dr. Andy Roark:
Yeah.

Dr. Anna McManamey:
You’ll get the occasional cat that just eats everything you put in front of them, but that’s not always going to be the case. So the good news is that cats with heart disease, again, HCM being the most common, really the only medication that we routinely recommend in these guys before congestive heart failure happens is a blood thinner and Plavix clopidogrel, we do think is probably better than just Aspirin for preventing that thromboembolic event. That’s that big scary thing that we really want to be able to just let clients know their cat has a risk for it. I would say a lot of ATEs aortic thromboembolism that I see, unfortunately it’s the first time the owner ever knew their cat had disease.

Dr. Anna McManamey:
So that’s the one that we’re trying to protect them with. And so really the left atrium has to be big for them to be at that risk. In most cases, I’ll say less than less than 5% of cats that have ATEs have a normal left atrium size. So most of the time their left atrium’s big. If they have a high BNP if I would say probably at least over 200 BNP range, if we echo them and they have a big left atrium, blood thinner is what we’re prioritizing in terms of treatment.

Dr. Andy Roark:
Okay.

Dr. Anna McManamey:
It’s a once a day therapy, it’s a small pill. So those things are in our favor.

Dr. Andy Roark:
Yep.

Dr. Anna McManamey:
Once heart failure happens, congestive failure happens, then it’s really Furosemide and they’re Plavix plus or minus an ACE inhibitor. We don’t have that same evidence that it has to have that ACE inhibitor to have a better prognosis once congestive heart failure happens like we do in dogs. Does it make sense that they would do better? Yeah, it makes sense, but we don’t have that exact evidence. So if congestive heart failure happens and I have a cat that the client can’t medicate, well, I’m just going to prioritize what I need to give them. And that’s their Lasix, which is a small pill and that’s their Plavix or some type of blood thinner to try to reduce that risk of an ATE.

Dr. Anna McManamey:
I have cats that are on injectable drugs. They’re on injectable Lasix because the owner can’t medicate them. So it’s kind of like a diabetic cat in that stance. So we’re just giving injections of Lasix twice a day, instead of giving oral medications. And you can coat the meds in some butter, you can coat them in cottage cheese, those kinds of tricks. But unfortunately, at least not yet are transdermal medications. I think that would be a godsend if we could get some bioavailable, transdermal Plavix or transdermal Lasix, something like that for these kind of cats. Yeah.

Dr. Andy Roark:
Okay. I was going to say no success in that regard so far.

Dr. Anna McManamey:
Not yet. Not yet

Dr. Andy Roark:
So I’ve heard people mention Pimobendan and cats.

Dr. Anna McManamey:
Yeah.

Dr. Andy Roark:
Is that-

Dr. Anna McManamey:
That’s yeah.

Dr. Andy Roark:
That’s kind of one of those back alley hey.

Dr. Anna McManamey:
Yeah. I was listening to-

Dr. Andy Roark:
Animal vet, come here.

Dr. Anna McManamey:
… one of your podcasts with Dr. Journey and she was… It’s the religion debate. Right. So-

Dr. Andy Roark:
Yeah.

Dr. Anna McManamey:
Yeah. So I would say that for the asymptomatic cat. So the cat that’s not in congestive heart failure. There’s probably no cardiologist that’s going to recommend Pimobendan in those cats.

Dr. Andy Roark:
Okay.

Dr. Anna McManamey:
So different than dogs. If there is a cat with congestive heart failure, some cardiologists might start Pimobendan in those cats. The rule for me is if there is a murmur, don’t give the Pimobendan because Pimobendan worsens dynamic obstruction. So if you already have a heart murmur, odds are it’s dynamic obstruction, giving Pimobendan will worsen that obstruction. So that’s kind of my general rule. If there’s a murmur and heart failure in a cat, just don’t give Pimo just stick with your Lasix, your Plavix plus, or minus your ACE inhibitor.

Dr. Andy Roark:
That’s super useful. Thank you for walking through this with me. Are there any final pearls or words of wisdom or pitfalls I should look out for just in general dealing with heart disease in a cat?

Dr. Anna McManamey:
Yeah. I think something that you actually mentioned in part of the history was coughing in cats. Coughing in the cat, rarely is from heart disease. Rarely is from congestive heart failure. I’d say the only times they see cats coughing with congestive heart failure is if they have a significant amount of plural effusion or a significant amount of pericardial fusion, which are both presentations of left sided congestive heart failure in the cat. So the coughing cat with a murmur to me, I actually move heart failure way down on my list and prioritize other things.

Dr. Anna McManamey:
The other little tidbit I’ll leave you with is if you’re in the ER setting and you tap a cat’s chest, do a thoracentesis and you just want to know, is this heart failure or not? You can run that sample on a BNP test. So you don’t even have to use the blood.

Dr. Andy Roark:
Really?

Dr. Anna McManamey:
And there’s these BNP tests, the B-type natriuretic peptide tests that are snap tests that are available for the ER setting. It just tells you, is it normal? Is it abnormal? That’s of same day test. It’s snap it’s eight minutes, but you can run that on blood serum or the plural effusion and you actually get a pretty good result with that.

Dr. Andy Roark:
That is super useful. Awesome. Thank you. Thank you. Thanks for sharing. I’ll tell you real quick. I remember being a first year veterinarian and I had a cat that had a chest full of fluid and I was going to tap it and the owner was there and I was getting ready to do it. And he said, “How many of these have you done before?” I was like, “I wish you hadn’t asked me that.” And then I was like, “I’m going to be honest,” and I’m like, “none but I’ve read about them.” And he was like, “I!s there someone else who could do this? And I had to go get… And I did, I went. The most humbling experience but-

Dr. Anna McManamey:
Oh my gosh. That’s-

Dr. Andy Roark:
I guess-

Dr. Anna McManamey:
That still happens to me. They’re like, “How many have you done?” And the devil on my shoulder wants to say, “Whether it’s one or a hundred, I’m all you got so you might as well.”

Dr. Andy Roark:
Yeah. Yeah, exactly. Right. Yeah. And just for me, I worked in a big practice. There were literally a dozen other vets. And they were like, “Why don’t you get somebody else junior?”

Dr. Anna McManamey:
It’s humbling.

Dr. Andy Roark:
Whenever I start to tap a cats chest I think how many of these have I done? It’s like, oh, a dozen. Okay. But, oh man, that’s funny. But yeah. Well the other thing too, you, how many of you done, you did a rotating internship, you did an emergency critical care internship, and then you did a residency. There’s probably not a whole lot that you haven’t done once-

Dr. Anna McManamey:
At least once so yeah.

Dr. Andy Roark:
… already so. At least.

Dr. Anna McManamey:
But it is. It’s always a little humbling and you’re kind of, eh, how do I answer that?

Dr. Andy Roark:
I’ve been doing vet medicine for 13 years and I am humbled every day and then I go in there and go, ah, oh, well, I love it. Yeah, I think if it wasn’t that way, I think it might get boring.

Dr. Anna McManamey:
Yeah I agree.

Dr. Andy Roark:
And that medicine’s a lot of things.

Dr. Anna McManamey:
Never boring.

Dr. Andy Roark:
Borings not one of them. Thank you, my friend. Thanks for being here.

Dr. Anna McManamey:
My pleasure. Thank you.

Dr. Andy Roark:
And that’s our episode, guys. I hope you enjoyed it. I hope you got turned out of it. If you did, please feel free to go leave us an honest review, wherever you get your podcast. It really makes a difference to me. It’s how people find us. It’s the nicest thing that you can do and it only takes a moment. Gang, that’s all I got. Take care of yourselves. Be well. I’ll talk to you soon. Bye.

Dr. Sheila Robertson is board certified in anesthesia and in animal welfare in the USA and Europe and serves as the senior medical director at Lap of Love Pet Hospice. Today, she joins Dr. Andy Roark to discuss a recent research publication on which she is an author: the 2022 ISFM Consensus Guidelines on the Management of Acute Pain in Cats. This is a great episode for anyone interested in getting our feline patients better pain control and generally better experiences in the veterinary clinic.

You can also listen to this episode on Apple Podcasts, Google Podcasts, Soundcloud, YouTube, or wherever you get your podcasts!

LINKS

2022 ISFM Consensus Guidelines on the Management of Acute Pain in Cats:

Feline Grimace Scale (Website & App):
https://www.felinegrimacescale.com/

AAFP Feline Friendly Handling Guidelines:
https://catvets.com/guidelines/practice-guidelines/handling-guidelines

Retain Your Team – Speak the Languages of Appreciation in Your Workplace: https://unchartedvet.com/product/appreciation-languages-101/

Creating Content Clients Crave: https://unchartedvet.com/product/creating-content-that-clients-crave/

What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Sheila Robertson graduated from the University of Glasgow in Scotland in 1980. After some time in mixed animal practice, she spent a year as a surgery intern followed by specialized training in anesthesia and analgesia at Bristol University (United Kingdom). While at Bristol she also completed her PhD investigating the physiologic effects of different anesthetic protocols in horses. She is board certified in anesthesia and in animal welfare in the USA and Europe and holds a certificate in small animal acupuncture. She has been a faculty member at the University of Saskatchewan, Michigan State University, and the University of Florida. Her research interests have focused on the recognition and alleviation of acute pain in cats, horses and even iguanas, topics she has published widely on.

She spent 2 years as an assistant director in the division of Animal Welfare at the American Veterinary Medical Association. In 2014 she completed her graduate certificate in Shelter Medicine at the University of Florida. In 2019 she received her certification as a Traditional Chinese Veterinary Medicine Palliative and End-of-Life practitioner by the Chi Institute of Chinese Medicine. Currently she is the senior medical director of Lap of Love Veterinary Hospice, a large network of veterinarians dedicated to end-of-life care and in-home euthanasia throughout the USA. Dr Robertson is also a courtesy Professor in the Department of Small Animal Clinical Sciences, University of Florida, Gainesville, Florida. She continues to volunteer at community cat clinics and High-Volume High Quality Spay and Neuter Programs.

EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:

Welcome everybody to the Cone of Shame Veterinary podcast. I am your host, Dr. Andrew Roark.

Dr. Andy Roark:

Guys, I am here today with the one and only Dr. Sheila Robertson. She was on the faculty at the University of Florida when I was there. She is board certified in anesthesia and animal welfare in both the USA and in Europe. She is absolutely brilliant and amazing. And she has got some new research out. She is an author on the 2022 ISFM Consensus Guidelines on the Management of Acute Pain in Cats. And I wanted to talk to her about acute pain and pain management in cats. And man, we get into it.

Dr. Andy Roark:

She’s super excited about the Feline Grimace Scale and the Feline Grimace Scale app, which I was unaware of. And so man, new tool in my toolbox.

Dr. Andy Roark:

Guys, this is a great episode. We really get into it later on talking about, the back half of the podcast, we get a lot into action steps and what we can be doing in the practices. That makes me super happy. Anyway, all-around great conversation. I hope you enjoy it. Let’s get into this episode.

Kelsey Beth Carpenter:

(singing) This is your show, we’re glad you’re here, we want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:

Welcome to the podcast Dr. Sheila Robertson. Thanks for being here.

Dr. Shelia Robertson:

Oh, thanks for inviting me. I listen in a lot. Never thought I’d be a guest.

Dr. Andy Roark:

Right. I have known you for some time now. You were on the faculty at the University of Florida when I was there. You were running my anesthesia rotation when I went through. And that was the first time I got to spend time with you. I’ve seen you lecture dozens of times since then all over the world.

Dr. Andy Roark:

You are the senior medical director at Lap of Love Pet Hospice, which is a group that was founded by some of my classmates and dear friends and they’re a great group. And gosh, you’re just everywhere. You work with the global pain council for WSAVA, which is the World Small Animal Veterinary Association. And you publish all over the place. And that’s honestly what I wanted to talk to you about today is a study that you have put out with a group of collaborators, it’s the 2022 ISFM Consensus Guidelines on the Management of Acute Pain in Cats.

Dr. Andy Roark:

And so this just came out in January. I think you were doing some speaking about it at the VMX Conference in Orlando. And I saw, I think you were on the agenda there talking about it, and I am a huge advocate for better care for cats and I think pain management in cats is something that we have not traditionally done as well as we should as a profession. And so I look at this and I say, “This is something that I would like to understand more.” And I’m always checking myself and trying to make sure that I’m practicing good medicine that I’m up to the current standards and things like that. So that is how I know you and kind of what I wanted to talk to you about today.

Dr. Shelia Robertson:

Yeah. Just so everybody knows what these are consensus guidelines.

Dr. Andy Roark:

Okay.

Dr. Shelia Robertson:

And ISFM stands for the International Society of Feline Medicine. So these are global. We wanted them to be able to be used around the world. Where access to different drugs and different types of therapy can be very different. So we wanted to make them global. And the group that put them together is Paulo Stegall originally from Brazil now working in Hong Kong. Myself, Brad Simon, who’s at Texas A & M, and then we have Leon Warren from Australia, was on them. And then Yael Shilo-Benjamini. She is actually based in Israel, did her training here in the US, and then Sam Taylor, who is a specialist, internal medicine and feline person in the UK.

Dr. Shelia Robertson:

So we got that group together and decided that it was time to really focus on cats and give them an entire paper to themselves, not kind of tagged onto the back of a dog paper. So these are completely feline only acute pain management guidelines.

Dr. Andy Roark:

So, let’s start at a high level. What are the objectives of the guidelines when you set out? So what were you trying to accomplish when you guys went to work on this?

Dr. Shelia Robertson:

Yeah. Well, so it almost like I can tell that you might have read them because one of the opening statements says, “Pain has traditionally been under recognized in cats.” And obviously if you under recognize it, that by default, means it’s undertreated, right? And we also know that pain assessment tools aren’t widely implemented. And so cats are very different from dogs.

Dr. Shelia Robertson:

I mean, cats are so good at hiding everything from people. And they’re not as demonstrative when they’re in trouble and we know that from other diseases. And so we wanted to raise awareness of the fact that they will be as painful as dogs after the same types of procedures or trauma, but there are lots of data to show that they’re not treated as well. People are, “Oh, I’m afraid to give a cat this,” because they have unique metabolism compared to dogs as well.

Dr. Shelia Robertson:

So the object was to really let people know that there are some very easy-to-use pain recognition tools out there that are now apps that you can put on a smartphone. And what does pain look like? And once you know what it looks like, you can actually score it. Because my philosophy is that we have an outcome measure for just about everything we do, right?

Dr. Shelia Robertson:

Say a cat comes in with a fever, like a very high temperature. So you can try and figure out was causing it. You treat it, but your resolution is, the temperature comes down, right.

Dr. Andy Roark:

Right.

Dr. Shelia Robertson:

If they’re diabetic, we follow their blood glucose. If have renal disease, we follow their blood work or SDMA. So what are people using as an outcome measure to say that they treated in pain effectively?

Dr. Andy Roark:

Yeah. It’s very little.

Dr. Shelia Robertson:

Other than I just think the cat looks better?

Dr. Andy Roark:

Right. Or, the cat seems more fractious and anxious next time it comes in and you think, “Oh, well maybe we didn’t do as good a job last time as we could have.”

Dr. Shelia Robertson:

Yeah. Yeah. And so we spent quite a bit of time putting in really nice real life images that each of us had of what feline pain looks like and how to examine a cat and recognize pain. And we did quite a lot on talking about the Feline Grimace Scale.

Dr. Andy Roark:

Yeah.

Dr. Shelia Robertson:

Which I like for a lot of quick assessments because it’s basically, you look at the face and they’re scored from zero to 10. Now that is now an app that can be downloaded on a smartphone. And yeah, it’s at the app store and everybody in the world has a smartphone. So you can download that app and use it cage-side to start scoring. You look at the pictures and you score their facial expression and it can tell you. And then if you instigate treatment, if you chose the right drug and did the right thing and things are better, the score goes down, right?

Dr. Andy Roark:

Yeah. I’ll put links to the app and also to the paper in the show notes so people can grab it.

Dr. Andy Roark:

So how widespread do you think that monitoring of pain in feline patients is in vet practices? Do you see practices that are doing good monitoring sort of patient care? And, I think a lot of us do a good job of recording hydration status, recording temperatures. Coming through and just checking on general wellbeing. Do our patients have food? Do they have water? Things like that.

Dr. Andy Roark:

Do you see a lot of practices that are doing an adequate, I’m just going to set the bar at adequate, do you see practices that are doing an adequate job of pain monitoring?

Dr. Shelia Robertson:

So I would say a lot of people using good protocols, but they’re not actually assessing how effective their protocols are. There was a paper just published very recently from a large number of veterinarians. And it was based in Australia and only 15% actually use a validated pain tool to assess pain in their patient population.

Dr. Andy Roark:

Right.

Dr. Shelia Robertson:

So they’re just doing it based on, well, I know if the cat is okay or not, right? It’s almost like you look at the cat and you guess that it’s temperature’s okay, but you don’t actually take the temperature.

Dr. Andy Roark:

Right? No, that definitely makes sense. Do you see good systems that people put in place? In your mind, when you see this, is this something that is hospital-wide, is this support staff technicians that are going by and sort of checking on this? Is it doctors? How sort of frequent in your mind does a monitoring system like this check-in on the patient? Is this an hourly check postsurgery? Help me dig into the specifics a little bit. I guess what I’m trying to do is really imagine this in my practice and what it could look like?

Dr. Shelia Robertson:

So when I was working in referral practice, so university practices, so we were getting pretty complex cases. And basically, my wing men and women are the anesthesia technicians, right? And I think that we need to empower technicians a lot more than we do, because if you think of yourself every day, Andy, you are probably in the surgery room or your surgeons are in the surgery room, doing surgery. The anesthesia techs admit the cat. It has an exam by a doctor and they often examine it. You check it over, you decide on a protocol, and they get it ready. So they’ve spent more time with the cat than you. So they know its personality, how it reacted to things. And then they take it to recovery. And they are really the advocate for that cat because they know how it was behaving before.

Dr. Shelia Robertson:

And obviously, if it’s now still nice and friendly and wants to play, everything went well. But if it’s not, they could come to you and say, “I don’t think this cat is doing very well.” And you might say, “Well, that’s your opinion. Let me look.” And so if you have a validated pain scoring tool, it’s no longer someone’s opinion, right? It’s well, here’s the temperature and here is its blood glucose level, here’s its pain score. So it gives them a lot more to advocate with and for everyone to focus on trying to get that score down.

Dr. Shelia Robertson:

And I think that is important because it empowers them. And there is a lot of what I know. I have pictures that I sometimes show when I go and visit hospitals, I’ll see notices on the front of a cat cage and it says, “Will bite,” and I’m like, “Why?” Does it bite because it’s painful. And if I ask, they go, “No, it’s just a evil cat.” And I’m like, “Well maybe it’s very anxious. Maybe it’s very afraid. Maybe it’s very painful.” So there is a lot of labeling and bias goes on and then people call it the diva cat, it’ll flinch if you just touch it. But to the cat, that pain is real and it will escalate with each visit if we don’t do the right things. And then we can talk later about the connection between fear and anxiety and pain because that’s more of a connection than we ever thought.

Dr. Andy Roark:

Yeah. So let’s go ahead and start to unpack that a little bit. So I, 100% resonate with what you’re saying about, “Oh, will bite. It’s a bad cat. She’s she’s evil.” Diagnosis, evil.

Dr. Andy Roark:

Why do you think that we don’t commonly make that distinction? Is it a lack of knowledge on our part? Is it a lack of understanding of anxiety, behavior, stress, or things like that? Why don’t we do a better job of understanding sort of why we get the reactions that we do from cats?

Dr. Shelia Robertson:

I mean, I think we’re all we’re moving in the right direction. And of course, there’s been a huge initiative for feeling friendly, cat-friendly practices. Lots of people understand how difficult it is to get a cat and a carrier and then drive it. A lot of them are motion sick and people don’t realize that, yet there are drugs we could give them to make them feel better. They could be dispensed with antiemetics before their next visit. And then a lot of people are using Gabapentin to sedate them. But remember that’s an anti-anxiety drug as well. And I think cats are, they don’t like change, but the biggest thing is they get very, very stressed when they don’t have control over their environment.

Dr. Shelia Robertson:

And they don’t get the same, I think, reassurance from having the owner there. A dog is with its owner and it obeys commands. I know we have difficult dogs to deal with but I think it’s more common in the cat. The cat really does not like a new environment and that new environment is extremely threatening to them when they don’t have control. And the control they have, in most threatening environments, is escape, right? And they don’t have that at your clinic. And then if they don’t live or haven’t been exposed to dogs and there are dogs barking and dogs smell, that’s very distressing to them.

Dr. Shelia Robertson:

So certainly understanding what an anxious, fearful cat looks like and what a painful cat looks like is important. But often they’re both. They can be painful and anxious and fearful and all of that is subversive and unpleasant. So we need to deal with all of it.

Dr. Andy Roark:

Yeah. So it sounds more like a holistic kind of generalized approach as far as low-stress handling. How we’re housing cats, things like that.

Dr. Andy Roark:

All right guys. This is when I jump in here with a couple of quick updates. First of all, the Uncharted Veterinary Vonference was last week in Greenville, South Carolina. It was amazing. We will have a virtual conference in the back half of this year. It’ll be in October. It is our GSD for Get Stuff Done Shorthanded.

Dr. Andy Roark:

That’s right. Get stuff Done shorthanded is going to be a virtual conference, which means you can join it anywhere. It will be in October more details coming soon. Registration is not yet open, but go ahead and get fired up. This is a great way to see what Unchartered is all about. See is it really different from everything else? Like people say it is, yeah. You can come and see just how that works online.

Dr. Andy Roark:

And then, if you love it, we’ll see you in person April next year in Greenville, South Carolina. Or, if you’re a practice owner, we’ll see you in person in December for our Practice Owner Summit.

Dr. Andy Roark:

Gang, if you can’t wait that long, and you know you can’t wait that long. We have a couple of workshops coming up. We have Retain Your Team. Speak the languages of appreciation in your workplace that is with Dr. Tracy Sands. It is on May 21st. It is all about showing your team appreciation. You know, they’re tired, you know they’re overwhelmed. You know that they want to feel appreciated for their work. Are you doing it right? Are you showing them appreciation? There are simple things that you can do that really make a difference. Guys, this is, as I said, May 21st 2:00 PM, Eastern, 11:00 AM Pacific time. It is $99 to the public. It is free for Uncharted members. Jump on, get registered, come and be there. This one is actually already filling up. It’s a month away and the spots are largely taken. So jump in there and grab a spot while you can.

Dr. Andy Roark:

On June the eighth, my friend, Bill Schroeder, founder and CEO of InTouch Veterinary Communications is doing his workshop, Creating Content that Clients Crave. This is all about making information in a way that clients will want to consume it. If you are tired of trying to educate in the exam room, if you want some backup, if you want some help, if you’re like, “I don’t have enough time to communicate everything, I need to communicate,” jump in on this webinar or, it’s a workshop, you’re actually going to work on the thing. That’s the difference in a workshop in a webinar, we do the thing, in Uncharted. June the eighth 7:00 PM, Eastern, 4:00 PM Pacific time. This is $99 to the public. Free for Uncharted members. You can hit the link in the show notes and get registered for that as well.

Dr. Andy Roark:

Guys, that’s enough for me. Let’s get back into this episode.

Dr. Andy Roark:

What do you think are the keys for sort of implementing this in practices? From the things that you see, what are the most important changes that sort of make you try to get practices up to speed? Are there approaches that seem to be particularly successful in getting the team on board and actually making changes?

Dr. Shelia Robertson:

Well, I think the AAFP has some very, very good courses that anyone can take. I mean, from veterinarians, technicians, and nurses, all the way down to anybody that even works in your clinic, and at very reasonable cost, can get certified or take a training course in how to handle cats and recognize, what they’re likely to do.

Dr. Shelia Robertson:

So I think the feline-friendly practice program is phenomenal and it’s coming up on its 10-year anniversary this year. And I think that’s made a huge difference to how we understand cats and allows people to work through learning about those things.

Dr. Shelia Robertson:

I think we all understand the exam room should be a little bit different. Using pheromones to calm animals or cats down. Owners can have a Feliway wipe in the carrier before they even come. And again, doing a cat exam, you can do a little bit, you can’t force it, right. You’ve just got to take your time. And I think the pre-visit Gabapentin, which is what most people use, some use Trazodone, but I think the pre-visit Gabapentin has been very, very successful for a lot of people.

Dr. Andy Roark:

Yeah. That’s a trend I definitely would like to see continue to spread. I’m amazed at how many practices do not have pre-visit Gabapentin or another sedative, anti-anxiety medicine pickup. It’s such an easy trick and pet owners appreciate it and it makes such a difference when people come in.

Dr. Shelia Robertson:

Yeah. And the stress itself can actually make you make a wrong diagnosis, right? They’re hypertensive, but they’re not really, it’s white coat hypertension, their blood glucose through the roof, because they’re so stressed out, and yet that could lead you down the wrong path with a diagnosis.

Dr. Andy Roark:

Yeah. What do you see as the biggest pushback that people run into as they start to improve their feline patient monitoring, things like that? Where, where are the pain points? Say that I wanted to advance this in my own practice as a veterinarian, where do people run into roadblocks?

Dr. Shelia Robertson:

I’ll be honest. I think a lot of people say, “Well, we know what a comfortable cat looks like.” And I thought I did until, I mean years and years ago started creating the Glasgow Acute Pain and validating that scale, which is more than just the face. The face is included, but it’s also palpation and so on. And I think what has been overlooked if a cat is sitting at the back of the cage, quiet and not moving, people have assumed it’s okay. And that’s actually the cat that I would now look at.

Dr. Shelia Robertson:

That would be a red flag because they’re at the back of the cage because they’re trying to hide and they haven’t been given a safe place to hide. Because that’s one of their coping mechanisms, right? They don’t have a box to hide in and they’re not moving because they’re painful and they’re not doing normal behaviors like getting up and having a nice stretch because their incision on their abdomen really hurts or they’re not grooming themselves because they hurt.

Dr. Shelia Robertson:

And then pain can make them nauseous as well and then they don’t want to eat in your clinic. I mean, a lot of them are just very suspicious of everything at the clinic. But use pheromones in their cage. And we do what’s called spot cleaning, which I learned from doing shelter work. Is that if it’s their own cage they will have taken the time to mark it and put their cheek pheromones on it.

Dr. Shelia Robertson:

All you need to do when you tidy up is just take anything that’s soiled, leave everything else because they’ve marked it and they’ve said, “This is my safe place.” So all I ever do now is clean up totally soiled articles in a cat cage and then give them a new towel that has been sprayed and left to air for 15 minutes with Feliway to put it in for security.

Dr. Shelia Robertson:

And again, noise, and partially covering the cage, and having the staff all know how to approach a cat, that not every interaction with the clinic should be for something to be done. I actually advise people when a cat is staying for several days that you should prescribe non-medical treatment. So the cat doesn’t anticipate that every time someone’s at the front of the cage, it’s going to be a pill. It’s going to be they’re going to do something to you. And we have good data, from again, from shelter medicine, showing that if you come up to the cage and just stroke the cat, pet the cat, and just have a safe interaction with it that doesn’t involve anything unpleasant, then everything’s much, much better.

Dr. Shelia Robertson:

It would take five minutes extra each day, or you could have volunteers obviously, that know that they’re going to not get hurt, open up and just speak to the cat and stroke it or get out a brush and brush it to help it because even that in itself releases endorphins and it is a good thing to do. But every single interaction usually is a medical interaction and they anticipate it, right?

Dr. Andy Roark:

Yeah.

Dr. Shelia Robertson:

I would too.

Dr. Andy Roark:

That makes perfect… Oh, absolutely. Sure, every time the door opens something bad happens and I get poked with a needle or grabbed by my neck or whatever, exactly. That doesn’t take long to leave a lasting impression about what’s going to happen.

Dr. Shelia Robertson:

So this not this like positive reinforcement that nothing bad’s going to happen. I’m going to groom you or I’m going to give you just a little bit of really super nutritious food, like a little piece of the tubes of Churu, which all the cats love. And they’re like, “Oh, okay. That was okay.” And then it was a predictable, positive interaction and I think they need, they need more of that. And I know everybody is busy. And then to have the time to do that before a treatment and then immediately after their treatment as well, if they’re getting an injection or something’s being done, would, I think, help lot.

Dr. Andy Roark:

Yeah. That makes a lot of sense. I mean, everybody’s busy at the same time. I mean what are the benefits to patient care? What are the benefits to reducing risk of cat bites and things like that by creating a better experience?

Dr. Shelia Robertson:

Well, yeah, I mean, there is good data to show that feline-friendly, trained practices have lower incidents of bite. Well, fewer people in the practice have a cat bite, and you know that can take someone out for days, right?

Dr. Andy Roark:

Yeah.

Dr. Shelia Robertson:

If they’re a surgeon they’re out for days. All has to be reported to HR and it’s horrible. So we know that cat bites can be reduced when people understand cats. And the other thing is a cat that is being totally defensive. You can’t nurse it, right? So the actual care of the cat is suboptimal. But if they’re very relaxed and feel secure, you can actually nurse them and take care of them.

Dr. Shelia Robertson:

They will want to eat, they won’t have GI stasis because they’re so fearful, which then in itself leads to all sorts of other problems. Hypertension, right? Is it real or is it that they’re terrified of being in their cage? So there’s just so much to understanding normal cat behavior and how to make it a better or experience.

Dr. Andy Roark:

No, that’s actually, that’s really great. That’s actually really useful. I’m going to sit with that. I like this a lot. Prescription snuggles, I think that’s fantastic. That makes me happy.

Dr. Shelia Robertson:

Yeah.

Dr. Andy Roark:

Let’s jump back for one second. So let’s say that I have that cat that’s just sitting at the back of the cage. So, I’ve got a patient, they had a fairly routine surgical procedure we’re going to say. Now they’re just sitting at the back of the cage and I’m hearing your voice in my mind saying, “You know, that cat at the back of the cage, that may be your painful patient.”

Dr. Andy Roark:

Can you walk me through just step-by-step? How would you assess pain in this cat. You talked about patient and things like that, but just run me through kind of what is your thought process as you are looking through the front of the cage and you see this cat looking back at you from the back?

Dr. Shelia Robertson:

Yep. So when we assess pain, we have two parts. We observe them only and we try and do that without them sort of knowing we’re there. So not right in their face, but just kind of have a look at them in the cage. So that’s going to let us see what their spontaneous pain behaviors are.

Dr. Shelia Robertson:

Now a spontaneous pain behavior in a cat is sitting still doing nothing but hunched up. That’s a pain behavior, but because it’s not throwing themselves around and wailing like a dog. It’s often ignored as an actual pain behavior.

Dr. Shelia Robertson:

And then we have what we call evoked pain behavior. So that’s when we have done the observation and then we actually interact and touch the wound. Sometimes that’s possible. Sometimes it’s not.

Dr. Shelia Robertson:

So for the cat, that’s sitting at the back of the cage, I would be, if I’ve downloaded, which probably everyone hopefully will do after this podcast, download the Feline Grimace Scale onto my iPhone. I’m going to pull it up. And I’m going to look at the cat’s face and start scoring it.

Dr. Shelia Robertson:

So we look at their ears, we look at their eye position, we look at their whiskers, we look at their muzzle, because it’s called the Grimace Scale for a reason, right?

Dr. Shelia Robertson:

When you’re painful, you kind of go, eh, and when you are a cat that makes your whiskers move, right? And your whole jaw and muzzle changes.

Dr. Shelia Robertson:

And then the other thing, which isn’t actually the face, but it’s the position of the head in relation to the cat shoulders.

Dr. Shelia Robertson:

So cats that are painful will just kind of drop their head down like this. But when they’re happy, their head is up, above their shoulders.

Dr. Shelia Robertson:

So those are the five things that you look at, and each is scored zero, one, or two. So you can have zero for the happiest, I’m doing great cat, and 10, yikes. Something’s really wrong. And round about four or five, we would say this cat needs rescue or needs to be looked at. What’s wrong?

Dr. Shelia Robertson:

Now the ear positions for pain and stress and fear are similar, right? So a cat that’s very fearful. Their ears go kind of flat. And so does a cat in pain. So we need to kind of figure out, and that’s why your nurses and technicians know when they come in for an elective procedure, they’re very unlikely to be painful, right?

Dr. Shelia Robertson:

So you do a baseline score. Now a baseline cat could score two for flat ears because is afraid. So what we’re looking at is differences in that score after the only thing you did before and after is do the surgery, right? So you’re looking for the pain scale or their score not to go up. You’re looking for it to the same. Maybe the flat ears. I’m still a little anxious, but not to go up.

Dr. Shelia Robertson:

And if you take care of anxiety, it’ll go down, right. It’ll be even better.

Dr. Andy Roark:

Yeah.

Dr. Shelia Robertson:

Right. If you take care of that. So that would be the first thing is look at their face. And then we look at posture. But I think people are finding the Feline Grimace Scale does correlate well with the Glasgow Acute Scale, which takes a little longer to do because then you interact with the cat. You touch it and stroke. Does it do the usual greet you? Does it not want to let you near it? Because that’s a bad sign. Do you hold their head, you should be able to touch around and palpate a wound gently if your pain management is adequate or good.

Dr. Andy Roark:

Okay.

Dr. Shelia Robertson:

Without them trying to turn around and nail you, they may flinch a little bit. And it also helps you look and see if your protocols are working most of the time and what I can do, even at feral cat clinics. I can go into one of those clinics, do the facial scale and show that their protocol works for most cats, like 96%. But there’ll always be a few that fall between the cracks, even with the same protocol. And that’s genetics, every cat’s different. It may have had previous pain. So it may already have come in with chronic pain that we don’t know about and we’ve added acute pain because we neutered it. But if I went into clinic and we’re rescuing, 50% of the time your protocol needs to be reworked, right?

Dr. Andy Roark:

Yeah. No, that totally makes sense. All that makes sense. I love the idea of a baseline score and it’s so simple it makes a ton of sense and it simply didn’t occur to me to do a baseline pain score on a cat. You go, “Well, you just came from home, the baseline score’s going to be 0. Well, no, we need to start looking at signs of stress.

Dr. Shelia Robertson:

And, the great thing about if you want to talk about continuing continuity of care when they go home before the owner leaves, they can download the Feline Grimace Scale app onto their phone, right? Or you can give them as part of their, like here. They could even do it at home before they leave to come in. Score their cat and then they can be monitoring the cat at home after a surgical procedure. And you know, you can say, “Well, if you score them with this app and their score goes back up to seven, you need to call us.” And it could be that the cat is getting more painful. Often it’s like, “Well you gave me those meds, but I can’t get her to take them,” right? And that’s why she’s painful. So it helps with the continuation of care at home.

Dr. Andy Roark:

Yeah. And so the app is approachable for vet owners.

Dr. Shelia Robertson:

Yeah. It’s free. It’s one of the number one medical download apps at the moment and it’s for Apple and for the other.

Dr. Andy Roark:

For Android, yeah.

Dr. Shelia Robertson:

It’s IOS and Android and Android. Yep. And it’s free. Yep.

Dr. Andy Roark:

Perfect.

Dr. Andy Roark:

Well, that’s awesome. I’m going to put a link down in the show notes. I’m going to link to the study so that people can download and have that as well. I’ll put a link to the AAFP courses for feline handling.

Dr. Shelia Robertson:

Yep.

Dr. Andy Roark:

Are there any other resources that you would recommend for my cat warriors who want to make sure they’re doing good pain control and learning what they can to be the best advocate for our feline patients?

Dr. Shelia Robertson:

Yeah. Well the good thing about the Feline Grimace Score, other than the app, they have their own website. And it’s now, the actual tool is in multiple different languages. So it’s in Spanish, it’s in lots of different languages because a lot of us have clients or people in our practice that English isn’t their first language. So that’s very positive.

Dr. Shelia Robertson:

And then the other thing, in there, they’re upgrading it more and more. So the really good thing about the Feline Grimace Scale, or tool, is that there is the app, but there’s their own website. And if you go to their website, it’s felinegrimacescale.com. You can get it in multiple different languages, the scale. It’s in Spanish, it’s in Portuguese, it’s in French, and so on. And on that website, they’re updating it all the time. What you can do, or your staff can do, is you can go in and score a cat and see how you compare to an expert that has scored that.

Dr. Andy Roark:

That’s cool.

Dr. Shelia Robertson:

So they’re doing it as a training center, right? You can go in, test yourself. Can I actually score a cat? And the answer is after a few minutes of training, owners can score a cat’s facial expression, whether it’s painful or not.

Dr. Andy Roark:

That’s awesome. That sounds like such a fun thing to do with the team. To say, “We’re going to do this together and everybody gets to do their scores and then we’re going to see what the experts come back at.” That’s really cool.

Dr. Shelia Robertson:

Yep. And then what I would remind people is, if you have a clipboard or you have an electronic, whatever you do for your postop monitoring, you’re probably going to put how much fluid they’ve had or are still having. If they ate. What their temperature is. What their pulse respiration is. Just add a line and put Feline Grimace Score. What was it?

Dr. Andy Roark:

Yeah, that’s awesome. I really appreciate it. That this has been wonderful. Thanks so much for… Thanks for all that you do for our patients. Thanks for taking time to be with us. Thanks for all the research resources. Like I said, I’ll link those down the show notes. I really appreciate you. Thank you for doing this.

Dr. Shelia Robertson:

Well, and I’m going to thank you for getting it out to the masses because that’s what we need. It’s the getting it out there and getting people just to say, “Yeah, wow, this is kind of cool.” And like I always have said, empowering our technicians and nurses that work with us, our support staff, because they’re with the patient more than we are usually.

Dr. Andy Roark:

Yeah. I completely agree. Awesome. Well thank you so much guys. Take care everybody.

Dr. Shelia Robertson:

Thank you.

Dr. Andy Roark:

And that is our episode guys. That’s what I got for you. I hope you did enjoy it. I hope you got something out of it. If you did, the kindest thing you can do for me is go in, leave an honest review wherever you get your podcast. If you didn’t enjoy it, then the kindest thing you can do is just not leave a review until next week when we have a whole new episode that you might like, and then if you do like it, then you can go leave an honest review. And that would be great as well.

Dr. Andy Roark:

So guys, that’s all I got take care of yourselves. Be well, I’ll talk to you soon.

This episode is made possible ad-free with the support of the Purina Institute!

Charlie, the 2 year-old labrador has crept from 76 lbs to 84 lbs over the last 6 months. We need to do something about this, and Charlie’s owners don’t seem super motivated to intervene. They’re good people, and they will listen if we can just communicate the right message in the right way.

Dr. Shelly Adrian, US Ambassador for the Purina Institute, joins Dr. Andy Roark to discuss this oh-so-common case and some resources that veterinary teams can use to have these conversations more effectively. Let’s get into this episode!

This podcast was brought to you ad-free by the Purina Institute.

LINKS

Purina Institute CentreSquare: www.purinainstitute.com/centresquare

Purina Institute: www.purinainstitute.com/

What’s on my Scrubs?! Card Game: drandyroark.com/product/card-game/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr Shelly Adrian received her DVM from Kansas State University College of Veterinary Medicine in 2007. She went on to a rigorous one-year private practice internship, mainly focused on Emergency Medicine, at the Pet Emergency & Specialty Center in San Diego, CA.

Dr Adrian remained with that clinic for an additional 2 years as an emergency veterinarian. In 2010, she entered general practice in San Diego, and continues to practice in coastal San Diego. Shelly’s areas of interest include nutrition, internal medicine, and emergency medicine. In 2015, Shelly joined Nestle Purina Pet Care as a Veterinary Communications Manager and was named a Senior Veterinary Communications Manager in 2019. Her current responsibilities include supporting several veterinary schools as well as providing education on behalf of the veterinary sales team. Shelly also took on the role of US Ambassador for the Purina Institute in 2021 and works to further communication to the veterinary community regarding the science behind nutrition.

Shelly resides with her physicist husband in San Diego and has three dogs: a 77-pound “greyhound-lookin’ thing” named Nutmeg, a young “Monkey” golden retriever mix, who she found on Petfinder.com, and their newest puppy “Walnut”.

EPISODE TRANSCRIPT

Dr. Andy Roark:

Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a good one for you today. I am here with my friend, Dr. Shelly Adrian. She is a veterinarian, a member of Uncharted, which is how I got to know her. She is also the U.S. Ambassador for the Purina Institute and I am talking to her about a case that you have seen, yes, you have.

Dr. Andy Roark:

It’s the young Labrador who is not wildly overweight yet, but we’re seeing it creep up. In this case, we’re talking about Charlie, the two-year-old Labrador retriever whose weight has crept from 76 to 84 pounds. And whose owners don’t seem super motivated to get involved with it. They’re like, “Oh, Charlie loves food.”

Dr. Andy Roark:

Listen, this is about team training is what it is. It’s about communicating effectively, it is about supporting our team as they have these conversations, it’s about veterinarians getting the same story and resources to back that story up from multiple team members. And so guys, Shelly is amazing at this really good conversation about how to approach this super common case. And let’s be honest, super important, right? We know that we expand pet’s lifespans when we manage their weight.

Dr. Andy Roark:

How do we do it? And the resources that Shelly brings to the table really fantastic. If you want your team to do better jobs, talking about nutrition, this is a great episode to get into and to share with them. Guys without further ado, we’re going to jump into this episode, which has been brought to you ad free by the Purina Institute. Let’s get into it.

Kelsey Beth Carpenter:

(Singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:

Welcome to the podcast, Dr. Shelly Adrian. Thank you so much for being here.

Dr. Shelly Adrian:

Thanks for having me, Andy.

Dr. Andy Roark:

It’s my pleasure. You and I have known each other for years. You are an Uncharted member and so that’s where we met back in the day, hanging out at those conferences and I’ve always enjoyed you very much. And I love to see you at our gatherings and our get together. You are a practicing vet in San Diego, and you are also the U.S. Ambassador for the Purina Institute. And I bring that up because it’s central to the conversation that I want to have with you today.

Dr. Andy Roark:

When we last spoke, you were telling me about one of your cases and we were talking about the hard conversation of getting pets to actually lose weight. I had a case yesterday and it was a 10 year old Yorkshire Terrier with collapsing trachea. And it came in and the owners were super nice. They were really great people, but they came in and they’re like the medications aren’t working anymore.

Dr. Andy Roark:

“I’ve been trying to medically manage this case and the medications aren’t working anymore.” And he’s just coughing all the time and whatever. And that little booger had gained a pound since the last time I saw him. And he’s only 10 pounds now. So even from nine to 10 pounds and they’re like, “He’s coughing all the time.” And I’m like, “Yeah, I suspect.”

Dr. Andy Roark:

And I know I talked with them about weight management and stuff before, and I went through like, “What are you feeding?” And it was this again, they’re wonderful people. And they clearly love this dog, but the list of things that they feed to this dog just kept going and it kept going. And there were pates and there were extra things that they were cooking and there were just these things.

Dr. Andy Roark:

And I’m like, this is a hard conversation. And it was a hard conversation, even though I’m like, here’s this glaring medical issue, right? It’s not like, Hey, it would be good if he lost weight. He’s like, no, you came here because he’s coughing and this is getting worse. And I’m like, we’ve got a pressing medical reason for him to lose weight and that’s still a hard conversation. And so that was just yesterday that I had that happen.

Dr. Andy Roark:

And then I step back and I really look at what we do for pets and what matters for pets. And when we think about the things that really affect the life of our patients, the two biggest ones in my mind are weight management, nutrition, and dental health, right? If you think about the goal for me is to increase the life span of the patients that I see, those are the ones I want to get right.

Dr. Andy Roark:

And then the last thing I’ll pull into this is the classic golden retriever study of dogs that are of an ideal body weight, or slightly thinner, live on average two years longer than those that are even slightly overweight. And so we know the importance of this conversation, but it is really hard to get traction on this conversation.

Dr. Andy Roark:

I know that people have a lot of frustration with this. So anyway, go back to our conversation and you and I were talking and you brought up, you were talking about resources that were there and then you had a case of how you would put those resources into use. And I want to unpack that with you today, if you’re okay with that.

Dr. Shelly Adrian:

Yeah, absolutely. And that nutrition conversation is vital, right? Nutrition is considered the fifth vital assessment. We know we have to have that conversation. We know our owners want to have that conversation with us, but…

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

Regardless of whether it’s a weight topic or what they’re currently feeding topic, it can feel very difficult and delicate and uncomfortable for us to have that conversation.

Dr. Andy Roark:

Well, there’s a couple pieces to it, right? There’s the denial piece when they… I never forget. I saw the most morbidly obese pet I’ve ever seen in my entire career. And I showed the pet owners, the body condition score chart, and I was like, which one do you think your dog is? And they pointed right at five out of nine. And I was like, which dog are you looking at?

Dr. Shelly Adrian:

I would say it by nine plus.

Dr. Andy Roark:

Yeah. But it was just like, there is that denial part of it and then there’s the food is love part of it. They have to believe that this is worth it, or it’s just so easy to fall off the wagon so it’s such a struggle.

Dr. Andy Roark:

But let me go ahead and open this up for you a little bit. Why don’t you just tell the story? Why don’t you tell the story that you were telling me before about the two-year-old Labrador?

Dr. Shelly Adrian:

Luckily, I saw this patient before it was in the situation that your York, he was in the other day, but…

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

Very classic patient that we see, I saw her in June 2021, for the one moment we were allowing clients in the exam rooms, Charlie, two-year-old female sped, Labrador was just there for healthy pet, no concerns, vaccines, except I had a concern when she came in, she weighed 84 pounds and previously she had weighed 76 pounds and the owner again, the denial part, right? The owner didn’t realize that those extra pounds can slip on you over six months. I think you’ve all experienced that. So I had to bring up a topic that the owner wasn’t prepared to talk about and draw her attention to a problem that she wasn’t aware Charlie had.

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

So I was able to use this new resource, this online toolkit that’s available to us from the Purina Institute and I had some secret knowledge of this toolkit. And what I was able to do was pull up a video for the owner on how to conduct a body condition assessment on your own pet.

Dr. Shelly Adrian:

And while I went to go get Charlie’s vaccines and vaccinate her, I was able to play that video in the exam room for Charlie’s owner to watch. And then when I came back, we talked about, what did she think Charlie’s body condition score was now being a typical owner after watching the video, she thought Charlie was a five out of nine.

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

Difficult. Right?

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

But on that same website, instead of having to open up a completely new tab and go to a new resource, I was able to pull up the body condition, score chart, and talk with her about what I was looking at when I’m judging Charlie’s body condition and showed her why instead of a five, I would actually grade Charlie at a six. And you’re right, I was able then very quickly to link to a resource that talks about that retriever study.

Dr. Shelly Adrian:

And it was perfect because Charlie is a retriever. And what they found was that paired litter mates who were just slightly heavier, typically those dogs were six and a half out of nine versus four and a half out of nine lived two years shorter than they’re lean lit made. So we have that conversation, we talked about Charlie’s ideal body, weight and body condition.

Dr. Shelly Adrian:

And I was able to print out a body condition score chart to send home with Charlie’s mom was able to print out a brief, or actually I emailed it to her after the exam. And it went through those key bullet points of why it’s important to have my pet at an ideal body condition. And most importantly, to help me feel comfortable having this conversation, it links published data.

Dr. Shelly Adrian:

So this is not just Dr. Shelly Adrian saying this isn’t just random veterinarian saying this. This is based on scientific data, not mentioning any type of specific product or biased in any way. It’s just based on scientific data. And then the cool part is, I just saw Charlie again, six months later, and guess who’s back down to her original body weight. So, how often does it happen and where that weight conversation works the first time?

Dr. Andy Roark:

Yeah. You won. You actually did the thing and got the pounds back off, as opposed to, all the other cases where you see the two-year-old and they’ve gained six pounds, and then next time you see them, they’ve gained another pound and then three more pounds. And now they’re 93 pounds and that’s where they’re just going to live for a while. You actually move the needle.

Dr. Andy Roark:

I want to unpack with you a little bit workflow, right? And one of the things that I think a lot about these days is how we do education in a way that actually reaches people. Some of the pushback that I get because I teach a lot about exam room communication, how we build relationship and how we build trust.

Dr. Andy Roark:

And people are always talking to me about time. Andy, we’re super busy, we’ve got people waiting, we’ve got all of these things and it’s so easy to push nutrition off of your plate and just say, this is not the most pressing thing. They didn’t ask me about nutrition. We can talk about it next time because the dog is still going to be a little bit heavy then and we can do it then.

Dr. Andy Roark:

And I want to be gentle and kind to my colleagues and stand in the exam room. I run behind schedule as well. I know how it goes at the same time when people press me on it and say, well, what do we do?

Dr. Andy Roark:

I really love the idea of using videos and using resources and things that we have in the clinic to let clients work or educate or to support the things that we’re saying when we’re not in the exam room. And so as you say, Hey, I ducked off to do these other things and I showed them this video, and when I came back, we talked more.

Dr. Andy Roark:

That is multitasking, right? That’s an efficient use of time. I’m going to hand you this while I go get these other things going and you’re going to stay engaged and we’re going to advance conversation while I’m in the back, drawing up, setting up [inaudible 00:11:20] getting my next appointment, ready, whatever the things that I’m doing, walk me through that workflow.

Dr. Andy Roark:

Like what exactly does that look like? Are you using tablet computers? I just want to start at the base level. I think I know other people really just want to visualize what this system looks like to get this education into the sessions.

Dr. Shelly Adrian:

That’s a great question and I’m just like you, I’m almost always running behind in the clinic. There’s so much information I want to convey to the owners and we have such a short period of time with them and it’s all critical, right? And I would argue you’re absolutely right that some of the most overlooked conversations are some of the most important and dental disease and nutrition are the top two because all of our patients have to eat.

Dr. Shelly Adrian:

And all of our patients at one time had teeth. So it’s really important that we never leave those pieces out. As far as workflow goes, it can vary from clinic to clinic the way my clinic works, we do have computers in the exam room that I can use. We could use a tablet if we chose to on that same resource, that online toolkit, I can email things.

Dr. Shelly Adrian:

And I did email something after the fact, it was really easy to just click a link and send that email to the owner. There are even additional resources that I could use to train my staff with videos or with reading. So the workflow, again, idea to save us time, to get us quick information, when we’re in the exam room too, what I find is a big area sometimes with nutrition conversations is when we look up good science backed conversation, we pull up some 12 page document that might take us an hour to read, right? And sometimes I just need the quick key messages.

Dr. Shelly Adrian:

I just want the bullet points. What do I need to say? What is the most important information to convey in less than five minutes? And so the nice addition to this tool is every piece of content has a reader watch time, so I can even filter. If I’ve got less than five minutes, what can I use to convey this information and go.

Dr. Andy Roark:

That’s super cool. Yeah. We need to be realistic about what people are going to actually do. Like sending them home with a multi chapter reading assignment is wishful thinking. And it’s just… I liken what we do to auto mechanic sometimes. And not in all cases I know people don’t like that, but for me, it’s the easiest thing that I can imagine that is expensive. It can get expensive real fast.

Dr. Andy Roark:

And personally, I’m not a car guy. I don’t know all that much. I want to be a good car owner. Obviously I want to have a car that works and have a nice long life from a car and I don’t know what I need and I don’t know what I don’t know.

Dr. Andy Roark:

And so when I think about education, I think a lot about my experience with an auto mechanic and stuff like that. And if I go to the auto mechanic and they give me a 10 page document to read with the specs of engine care, it’s not going to happen and you know what’s not going to happen. You and I were talking before, as we were making this COVID pandemic spike, my kids have been doing virtual school for a while.

Dr. Andy Roark:

Everybody around me is sick. Yeah. And it’s like, we are all busy and we’re all stressed. And so just meeting people where they are and being realistic and just giving them the actual information that they’re going to use to make a decision and then giving the pathway to where they can go deeper if they want, right?

Dr. Andy Roark:

I think that’s probably the key with a lot of the clients and trying to educate us. We all have those clients who are sponges. They want to read all the things, they want the 12 page document, and they want to see the original sources. It’s a beautiful thing to be able to give people the executive summary and then have it link deeper, have the ability to go deeper to what they want.

Dr. Andy Roark:

But I think a lot of times we jump to the full Monty and people are not ready for that. And it just goes into their email and it just sits in their inbox for a long time because they didn’t delete it because they mean to read it. They just never do.

Dr. Andy Roark:

And so that’s super interest to me just short my time and have stuff that’s top level. And what… Can I ask you some more questions about the training stuff because that’s really intriguing. I’m a super big advocate for tech training for helping people grow and develop inside the practices.

Dr. Andy Roark:

I like people to be learning new things. I want to learn new things and so I’m always interested in what training resources and stuff are there, can you lay out what’s there and what might be beneficial to practices?

Dr. Shelly Adrian:

I thought that might pique your interest. Yeah.

Dr. Andy Roark:

Yeah. I love it.

Dr. Shelly Adrian:

And that’s the neat thing like you said, some folks want those key bullet points, those key messages and that’s all they need to know. I don’t know what a carburetor is. I’m never going to read further about what a carburetor is, I just hope that it works. Sometimes I really do want to read deeper into what makes a large breed puppy food different than a regular puppy food, right?

Dr. Shelly Adrian:

And so do my technicians because let’s be honest, they might be the ones having the conversation about large breed puppy food versus regular puppy food. So what we can utilize on that center square toolkit, there are videos, there are right ups again with those key bullet points, but then linking to deeper, more science getting into that nitty gritty, that nerdy part.

Dr. Shelly Adrian:

And again, always based on published data, the videos are really cool though and I pull those up frequently just for myself. If I have a few minutes to inhale my lunch, most of the videos are less than five minutes long and they’re recorded by board certified veterinary nutritionists. These are nutritionist that do not work for Purina.

Dr. Shelly Adrian:

So this is not Purina centric at all, and they have really helpful videos about how to fit that nutrition conversation into a short exam. How to have a conversation with an owner who comes in with recommendations for foods, perhaps from a breeder or a shelter that maybe we don’t agree with those recommendations for that pet, the importance of a nutrition conversation.

Dr. Shelly Adrian:

They hit all of those difficult topics and give their pearls and their best practices because they’re having those conversations too, right? So listening to their perspective on it just while I’m inhaling my food, watching that quick video is not only helpful for me, but for my staff as well. And then if they want to dig deeper, they can look below the video and it will link them to some of the deeper information on that same topic.

Dr. Andy Roark:

That’s awesome. I really like it a lot. Can you help me with… So the last part of this for me, that I find is a hurdle to really leveraging resources effectively is what I say in the exam room. Can you help me with some conversation stuff just to set this up to then refer them to some resources and things like that?

Dr. Andy Roark:

You have a lot of experience with this. How do you broach the conversation of either, Hey, I’m going to leave you with this video or I want to send you with more information and I’m going to send this as a link or I’m going to print this off.

Dr. Andy Roark:

What strategically do you do to set up the conversation so it doesn’t sound like, Hey, I know we didn’t talk about this, but here’s bunch of links because that’s not going to go anywhere either way, so you’re naturally a very warm and charismatic person.

Dr. Andy Roark:

How do you lead into this conversation to get people to actually click the links and to feel like, yes, this is not homework for me, this is a value add to my exam.

Dr. Shelly Adrian:

That’s a good question and you’re right. We don’t want to information dump or sometimes we do want information dump, but we know that’s not effective.

Dr. Andy Roark:

Right. Always want to information dump.

Dr. Shelly Adrian:

But yeah. So, I think a part of it is going back to the idea that we’re on the same team.

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

We both want what’s best for their pets health and going back to the idea that food is love, I almost by nutrition to be a topic that usually does peak owner’s interests and as opposed to my car’s carburetor…

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

That the nutrition piece is something they want to eat. So, when I bring up the nutrition conversation, which I always at least mention a piece of nutrition in the exam room, we always talk about what food they’re currently eating the body condition score. So as I go back to that, Hey, remember we talked about, your dog is eating X, Y, Z. The reason I like X, Y, Z food for fluffy is, and then if you want to read more up on that, say, for example, I’m seeing a geriatric cat, this is another true life example, geriatric cat named Angelina 17 years old.

Dr. Shelly Adrian:

It was healthy but she was getting to that where she’s getting leaner and thinner and losing that lean body mass. So we talked about the food she was eating, which was good. But what I said for her is, Hey, I want to focus a little bit more on getting more water into her, help with her kidney function and just for geriatric cat in general, and getting some extra protein into her for that lean body mass.

Dr. Shelly Adrian:

So, if you want to read further on why I’m making that recommendation, I have this link for you. In the meantime, here are some solutions as far as getting more water into her and getting more protein into her. Does that make sense?

Dr. Andy Roark:

Yeah, I like that a lot of, Hey, if you want to get deeper into why I’m making this recommendation, that’s the words that I like, I’m going to put that into my little quiver of arrows for the exam room, because that makes sense for me as well.

Dr. Andy Roark:

So no, I like that a lot. That really makes sense. One of the things I think is true with nutrition, right? I think it is true of people in general, but I think it’s also especially true of people with pets. I think we also want to have control in our lives. I think we all want to believe that we have some control and we want believe that we can keep ourselves.

Dr. Andy Roark:

And I think this is obviously COVID thoughts with Andy. We all want to believe that we can keep ourselves and our family safe, including our pets and nutrition is a thing that we have great control over for our pets. It is a thing where we can make this purchase and we can decide what they get. And this is an aspect of their life that we can control, which is why people talk to us about their pets stool all the time.

Dr. Andy Roark:

Because they’re like, they can see it and it’s there and I can adjust what’s going in, the front side and effect what’s going on the backside and this is control I definitely have. And so I do think that in that mindset, nutrition is really easy to talk about and I do find that pet owners are generally psyched to get a recommendation, to start to Wade into it.

Dr. Andy Roark:

There’s also some research that came out and I’m not going to try to quote the staff because they’ll be off, but I was actually surprised by the high percentage of pet owners who say that they want nutritional recommendations from the doctors and they want to talk about nutrition. I think a lot of us go, they made a choice and this is bringing up old stuff but the research doesn’t, that’s not true.

Dr. Shelly Adrian:

You’re right. And I’m super nerd. I actually do know this stuff.

Dr. Andy Roark:

So I thought, I’m going to toss this out there at half date and I’m going to let Shelly just finish cooking it for me.

Dr. Shelly Adrian:

And I think it’s really important for us to keep this in mind because again, I’m in San Diego. I have had the challenging nutrition conversations and I know what it’s like…

Dr. Andy Roark:

Oh, I’m sure yeah.

Dr. Shelly Adrian:

Talking and you feel like you’re talking to Rick wall, but they hear you. 83% of owners trust their veterinary professional when it comes to nutrition advice, however, less than 25% perceive that they’re getting that nutrition conversation when they go to the vet.

Dr. Shelly Adrian:

So it’s a real… That’s why I think it’s important to have those additional resources say, Hey, if you want to read more, because if they have those, whether it’s an email or a video, we showed them or a printout that we leave them going home with, now they know they’ve had that nutrition conversation, right?

Dr. Shelly Adrian:

So now they’re going to see, yes, I got this recommendation from my vet, whether it was about body condition, score, specific diet, hydration, and whatever, the aspect of nutrition that conversation you’ve had, they know they had that conversation with you and that just builds to a better relationship overall, right?

Dr. Andy Roark:

Yeah. I agree. I want to leave you with a bonus round here and you can take either of these two questions. You can either leave me with your favorite Pearl for getting nutritional compliance, getting people on board, getting people to make changes that you think that most GPS or technicians miss, or you can give me the biggest pitfall that you see in these conversations that most of us fall into. Which one do you want to do? You can take either one yeah, I know.

Dr. Shelly Adrian:

I think the biggest pitfall that I see from my colleagues is shying away from the nutrition conversation. And there are lots of reasons why we might not feel comfortable having it. We might not be fully up on the science ourselves, right? So if we get questioned, we’re not sure that we can justify the recommendation we’re giving, or we don’t know how to have that conversation.

Dr. Shelly Adrian:

But I challenge you to take the conversation back because as we already discussed, the owners want it. If they don’t get the information from their vet professional, they’re going to get it from somewhere. And we have tools available to us that are backed by science. So if you take a step back and you just approach it as a teammate with the owner, right, we’re part of a team to keep this pet healthy.

Dr. Shelly Adrian:

And what does the published data say about this pet’s nutrition? And if we just go back to what our resources and our published data give us, it can take some of the emotion out of it and it makes it less difficult. So I challenge you, especially those times where you really don’t want to have the conversation, do it.

Dr. Shelly Adrian:

Have the conversation backed by science, give a specific diet recommendation every time whether it’s stay on this food, it’s great, I love it. Or I recommend X diet because this is Y.

Dr. Andy Roark:

Yeah.

Dr. Shelly Adrian:

And back up, site your source back up your reasoning.

Dr. Andy Roark:

Yeah. What’s the easiest way or the best way for people to engage with Purina Institute and Center Square? I’m going to put links in the show notes for everybody who wants to click through. But yeah, if people are out there and they’re listen to, as they drive in and they’re like, Hey, I want to look around, I want to see this thing. How would you advise them to get started?

Dr. Shelly Adrian:

Perfect. Yeah. The Purina Institute is the scientific arm of Purina, and the goal of the Purina Institute is twofold. In general, is to generate and communicate scientific content on companion animal nutrition, but also to help us take that conversation back to help us have these difficult nutrition conversations. So if you just go to the website, Purina institute.com, there’s a wealth of information there.

Dr. Shelly Adrian:

If you want to get real nerdy on it, you can, whatever the topic may be. The nerdy shell, you had to come out but there’s a label at the top called Center Square and if you just tap on that, you can search the wealth of resources. I encourage you to play with it, whether it’s veterinarian, technician, receptionist, there’s content there that can help you have those nutrition conversations because we all do.

Dr. Andy Roark:

Yeah. Awesome. Thanks so much for being here. I really appreciate you. Appreciate your time.

Dr. Shelly Adrian:

Thanks for the Sandy.

Dr. Andy Roark:

And that is our episode. Thanks again to the Purina Institute for making this possible guys, thank you for tuning in and checking it out as always, if you like the episode and you feel like leaving us an honest review, wherever you get your podcast, that means the world to me.

Dr. Andy Roark:

I really do appreciate it. Also, remember that we are now on YouTube. So if you like watching podcasts or watching the conversation, check us out there. Anyway, gang take care of yourselves. Be well, talk to you later. Bye.

Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram

A 6 month-old bearded dragon presents for shaking and not eating. Dr. Doug Mader walks us through the best way to approach this case and discusses why Metabolic Bone Disease (MBD) is a term we should think twice about using.

You can also listen to this episode on Apple Podcasts, Google Podcasts, Soundcloud, YouTube, or wherever you get your podcasts!

LINKS

Dr. Mader’s Website: https://www.dougmader.com/

Follow Dr. Mader on Facebook: https://www.facebook.com/douglas.mader.9

Retain Your Team – Speak the Languages of Appreciation in Your Workplace: https://unchartedvet.com/product/appreciation-languages-101/

What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Douglas R. Mader, MS, DVM, Diplomate ABVP (Canine/Feline), Diplomate, ABVP (Reptile/Amphibian), Diplomate, ECZM (Herpetology), Fellow, Royal Society of Medicine

Dr. Mader received his DVM from the University of California, Davis in 1986. In addition, he completed a Residency in Primate and Zoo animal medicine. He is the consulting veterinarian for the Monroe County Sheriff’s Zoo, the Key West Aquarium, Dynasty Marine, the Sea Turtle Hospital, the Everglades Alligator Farm and the Theater of the Sea. Previously Dr. Mader owned the Marathon Veterinary Hospital, a double AAHA accredited 24 hr emergency/referral hospital. Dr. Mader is an internationally acclaimed lecturer and is on the review boards of several scientific journals. He has published numerous articles in scientific and veterinary journals, national magazines, and, is the author/editor and co-editor of three textbooks on Reptile Medicine and Surgery.­­ Dr. Mader’s latest project is his new book “The Vet at Noah’s Ark – Stories of Survival from an Inner-city Animal Hospital.”

EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:

Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here today with a legend. The one and only Dr. Doug Mader. If you don’t know Dr. Mader, he wrote the book on exotic animal medicine.

Dr. Andy Roark:

The guy has been elected the Speaker of the Year for Exotics at the VMX Conference, which is one of the largest conferences in the world, something like seven times. It’s incredible. When you listen to this interview, you’re going to find out why. Because he knows his stuff and he breaks it down in a super useful, tangible way.

Dr. Andy Roark:

I’m not a big exotics vet. It’s a weakness of mine. I’m very upfront about that. And so, whether you do exotics all day every day and you’re just looking for pearls from the master. Or whether you are not real comfortable with exotics and you want to get the basics and understand the fundamentals.

Dr. Andy Roark:

Gosh, this is a great episode. Thank you to Dr. Mader for being here. Guys, let’s get into this episode.

Kelsey Beth Carpenter:

(Singing) This is your show. We’re glad you’re here. We want to help you and your veterinary career. Welcome to The Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:

Welcome to the podcast, Dr. Doug Mader. Thanks for being here.

Dr. Doug Mader:

Dr. Roark, thank you so much for the invitation. I really appreciate it. It’s quite an honor.

Dr. Andy Roark:

Well, call me Andy. I’ve been a fan of yours for about 15, almost 20 years now. I was aware of you in vet school, because I went to Florida. Your practice was in … Was it Marathon, Florida?

Dr. Doug Mader:

Yeah.

Dr. Andy Roark:

You would take externs down there, and the people who went got to do these incredible things. You worked on alligators and sea turtles and just amazing stuff.

Dr. Andy Roark:

And then, I’ve seen you lecture a number of times. You have been the Speaker of the Year at VMX, which is one of the biggest vet conferences in the world, seven times for exotics. You’ve got a book coming out in June.

Dr. Andy Roark:

First of all, you have an amazing career, and you are also an excellent teacher. Thank you for taking time to be here. I really appreciate it.

Dr. Doug Mader:

It’s quite an honor to be invited. Thank you.

Dr. Andy Roark:

Well, I’ve got a case for you. And so, I have to start with full disclosure. Exotics are a weakness of mine. I am a general practice doctor. And so, they come across my desk and I want to be competent. At least get people started and do help where I can do help.

Dr. Andy Roark:

And so, it’s in that. Just know that’s my background. But I am coming to you with a case that I am looking at. I was wondering if I could walk you through it?

Dr. Doug Mader:

All right.

Dr. Andy Roark:

All right. I have got a bearded dragon. This pet was purchased from a pet store. It’s about six months old. The owners have brought it in and they’re not sure what’s going on with it.

Dr. Andy Roark:

It’s shaking and it can’t walk. I’m not … They’re telling me that it’s also not eating. I’ve taken some radiographs. I don’t really know what I’m looking at. To be honest, I don’t see anything obvious. It seems, to me, to be relatively decent.

Dr. Andy Roark:

It doesn’t look like an emaciated lizard that hasn’t eaten in an extended amount of time to me. But that’s what I’m looking at. Can you help me get started in this case and at least take it in a useful direction?

Dr. Doug Mader:

All right. That’s good to know. There are a lot of, especially with bearded dragons, there are some diseases of high concern. Such as adenovirus. That hits them when they’re about four months of age. Anywhere between four and 11 months of age. It shows up as kind of a chronic wasting.

Dr. Andy Roark:

Okay.

Dr. Doug Mader:

Oftentimes, they develop some neurologic symptoms. They can’t walk and of course they don’t eat. But usually, these animals are emaciated when they’re advanced. What you’re describing sounds almost acute, in terms of the anorexia or the hyporexia.

Dr. Doug Mader:

Young, growing animals, especially insectivores and herbivores like Iguanas … Insectivores, of course, like the bearded dragons. Of course, keep in mind, beardies also eat a lot of vegetation. And then, insectivores like chameleons, for instance. We see this frequently in those.

Dr. Doug Mader:

You have to worry about something called nutritional metabolic bone disease. Or the proper term, the veterinary term, is nutritional secondary hyperparathyroidism. If I can jump on my high horse here for a minute. That is … You hear veterinarians talk about MBD. Metabolic bone disease.

Dr. Andy Roark:

All right.

Dr. Doug Mader:

There is no such thing as MBD. MBD is a category. Metabolic bone disease, for instance, covers a whole variety of different metabolic pathologies of the bones. Osteoporosis, osteomalacia, panosteitis, hypertrophic osteodystrophy. A whole litany of them.

Dr. Doug Mader:

The two main ones that we deal with, especially with reptiles, is nutritional secondary hyperparathyroidism, which I coined the term, “NMBD,” years ago. And then, the other one is in adult animals. And that’s renal secondary hyperparathyroidism or RMBD. Based on what you told me, we have to look at the obvious.

Dr. Doug Mader:

If it’s got hoof beats, you think horse first. A young, growing insectivore, less than a year of age. They’re in a rapid growth phase. They’re having difficulty ambulating. They’re not eating well. We have to assume … You’re in South Carolina, right?

Dr. Andy Roark:

Correct.

Dr. Doug Mader:

I’d imagine in the winter, it gets cool?

Dr. Andy Roark:

Yeah.

Dr. Doug Mader:

Not like where I live here, where it’s 85 degrees in the winter. All right. We have sunshine year round. We’re probably looking at nutritional secondary hyperparathyroidism, which is NMBD. And that’s by far the most common cause.

Dr. Doug Mader:

How does that fit your patient? NMBD. It’s a triad of vitamin D3 from the sun, calcium in the diet, and temperature. One of the big things that a lot of people tend to neglect is temperature. And I’m going to use the iguana as an example. Because we have wild iguanas in my yard where I live on the island.

Dr. Doug Mader:

You’ll not uncommonly see them out basking. And it can be 95 degrees outside. If you go and catch that animal and you take a core body temperature … Just take a thermometer, dog and cat thermometer, and slide it in the cloaca carefully. The body temperature going to be 105.

Dr. Doug Mader:

Everybody assumes, “Well, these are cold blooded animals. The body temperature is going to be the same as the ambient temperature.” It never is. So if they have proper husbandry, if their cages are set up with focal heat spots and warming areas … I hate to use the term, “hot rock,” because those dangerous.

Dr. Doug Mader:

But if you have a heating area, so they have a thermal gradient in their cage. They, via temperature regulation behavior, will thermoregulate. Typically, their body temperature is much higher than the ambient temperature of the air.

Dr. Doug Mader:

Getting back to that. The iguana’s ambient normal temperature range is 88 to 104 degrees. You live in South Carolina. They have a pet iguana or they have a pet bearded dragon. They let it run around the house. Well, what’s the temperature in your house?

Dr. Andy Roark:

70.

Dr. Doug Mader:

Room temperature when we have the heater on. It’s 68 degrees. The 88 degrees is the low end for the iguana. Guess what, Andy? That vitamin D pathway. Reptiles need vitamin D3. And if you remember your physiochemistry, there’s that whole cycle where sunshine heats the skin.

Dr. Doug Mader:

It changes ergocalciferol into cholecalciferol. It goes to the liver, where it becomes hydroxycholecalciferol. And then, it goes to the kidney where it becomes dihydroxycholecalciferol. Those reactions … They’re enzymatic reactions and they have a temperature peak.

Dr. Doug Mader:

The temperature at which it gets the second hydroxylation is 88 degrees. So if you’re keeping that iguana or you’re keeping that bearded dragon in your house at 72 degrees or 68 degrees or wherever you sit your thermometer … Even if you give them proper lighting, even if you give them proper calcium in the diet, they’re too cold.

Dr. Andy Roark:

Right.

Dr. Doug Mader:

They can’t metabolize the vitamin D. If they can’t have metabolize the vitamin D to the active form of D3, they’re not going to absorb the calcium from the GI tract. People forget how complicated it is.

Dr. Doug Mader:

It’s really, really basic. But it’s really important. All of the DVM degrees that we have aren’t going to help if the owner doesn’t meet husbandry. Getting back to your question. You need to talk to the client. Find out, “How do you house this animal?”

Dr. Andy Roark:

Okay.

Dr. Doug Mader:

First off, you need to know what the normal temperature range is for a bearded dragon. It should be somewhere between 80 and 90. They’re not nearly as hot as an iguana. If they’re keeping it in their house and it’s not 80 degrees, it’s not going to grow properly because it can’t process.

Dr. Doug Mader:

All right. What are you feeding it? “We’re feeding it crickets.” That’s not their natural diet. In the wild, these guys are heavy herbivores. They eat a lot of vegetables. They do eat some crickets. You’ll find a lot of the pet stores will just sell crickets.

Dr. Doug Mader:

You say, “Okay. Well, crickets are in a balanced diet.” And then, the client will tell you, “Okay. Well, we got loads of crickets.” Well, again, that’s a contrived diet. There’s a lot of different insects available and I don’t have the time on this podcast. Maybe I can come back and we can talk about nutrition.

Dr. Doug Mader:

But the bottom line is they need to be feeding a balanced diet. Let’s just encapsulate that for now. They have to have the right temperature, the right diet. Then, they have to have the proper lighting. And the UVB lights are extremely important. The UVB range is about 290 to 320.

Dr. Doug Mader:

All of these reptile bulbs that are on the market … They have UVA, UVB, and UVC in it. Interestingly enough, if you can see my hands … Let’s say this is a light. The amount of UVB that’s produced by a bulb this big is only in the center about 2%.

Dr. Andy Roark:

Got you.

Dr. Doug Mader:

That’s it. And that only travels about 18 inches. So if they’ve got a light on the ceiling or it’s an old light? The phosphorus will wear out on the inside. It doesn’t produce any UVB.

Dr. Andy Roark:

Got you.

Dr. Doug Mader:

Again, everything interacts with itself. A big part of what you do as the doctor, when you talk to this client, is you got to play detective. You got to get all these facts. Because you can give them all the right medicine.

Dr. Doug Mader:

I can tell you what dose and what milligram to give, but if they don’t do their homework, everything you do is not going to work. And then, they get upset with you as the vet. Because, “I spent all this money and it’s still not getting better.” Well, you did everything right. But it’s the teamwork.

Dr. Doug Mader:

X-rays. Sometimes it’s hard to tell. You take an X-ray and some of these reptiles, especially the bearded dragons, they’ve got all those spikes and thorns and everything. It’s hard to see what’s on the inside. It really is. So if you can’t tell, don’t feel bad. Because a lot of us can’t tell.

Dr. Doug Mader:

Especially, in the young, growing animals. They don’t have fully calcified bones anyway. Because they’re still young and growing. But then, if you add in, on top of that, an animal that’s got nutritional metabolic bone disease … The bones are softer and they’re not as radiodense, so it’s hard to assess.

Dr. Andy Roark:

Got you.

Dr. Doug Mader:

Things like pathological spinal fractures, which may be why it’s not walking. You may not see it just because it’s really hard. Don’t feel bad about that. I’m glad you took the radiographs. Because oftentimes, if they’ve got really good bones, that’s important. But oftentimes, it’s iffy. It can be a challenge.

Dr. Doug Mader:

Other things that you can do. I hear about veterinarians, “Well, let’s take some blood and do an ionized calcium.” You can do that. I’m a pet owner too. I’m actually a retired veterinarian now. When my pets get sick, I got to go to the doctor.

Dr. Doug Mader:

And I do look at the cost. All right. Do we need to run an ionized calcium? That’s an expensive test. Or do we say, “Young, growing herbivore in South Carolina that’s housed inappropriately …” Come on. If you hear the hoof beats, it’s going to be nutritional metabolic bone disease.

Dr. Doug Mader:

We can run ionize calcium, so that we can go, “I’m a good exotic vet, because I ran ionized calcium.” You don’t need to do that. Respect your client’s wallet. They’ll respect you for that too. It’s not going to change how you’re going to treat this.

Dr. Andy Roark:

That was my question. Am I getting information there that’s going to change how I treat it?

Dr. Doug Mader:

No. Not at all.

Dr. Andy Roark:

Okay.

Dr. Doug Mader:

You’re going to go, “It’s slow. It’s slow. I’m so brilliant.” Come on. Yeah, you can do it. If you’ve got the Titanium American Express card and the client says, “Do everything.” Do it. Do you need to do it? No.

Dr. Andy Roark:

Got you. Okay.

Dr. Doug Mader:

I wouldn’t do it. Blood work … Usually, you can run a CBC/chem. And that’s nice. I don’t think you need to. Again, look at what’s in front of you. Use your experience or rely on what you learned from other people.

Dr. Doug Mader:

If you suspect this animal is ill, that’s different. If you think he might be septic, let’s run blood work. Let’s look at the leukocyte morphology. Let’s go and get a PCV.

Dr. Doug Mader:

Make sure that he’s not anemic. Blood’s a nice backup. I do like to do blood work. I think it’s important. Can you still treat this animal without it? Yes. If the client is financially restricted, you can treat it without it.

Dr. Andy Roark:

Hey, guys. I got to jump in here real quick with just a couple of quick updates. First, I got to give some love to Banfield Pet Hospital. Guys, they’ve been making possible transcripts for this podcast for a while. They’re doing it for the whole year.

Dr. Andy Roark:

It is something that I really wanted to have happen. And it’s something they stepped up in the name of increasing accessibility and inclusion in our profession. Providing information so that everybody can have access to it. Anyway, it was a wonderful thing that they did not have to do, that they said was their mission.

Dr. Andy Roark:

And then, they followed through and really made this thing possible. Anyway, spread the word for anyone who would take advantage of transcripts of the episodes. We are so happy to offer them. You can find them at drandyroark.com. There’s links in the show notes below down to that.

Dr. Andy Roark:

Guys, let’s see. What else have we got going on? We have got, over on the Uncharted Veterinary podcast … If you’re a podcast listener, you might be interested in the other podcast that I host with my friend, Stephanie Goss.

Dr. Andy Roark:

Last week, we did an episode on, “What happens when your direct boss’s style is the polar opposite of yours?” How do you survive? How do you bridge the gap? How do you work effectively? If that’s of interest to you, check out the Uncharted Veterinary podcast. The link is in the show notes.

Dr. Andy Roark:

This week, it came out yesterday, we’re talking about, “Do you really need an online pharmacy? How do you make it worth your while?” Anyway, guys, those are some episodes over at Uncharted Veterinary Podcast. Take a listen. See if they’re for you. With that, let’s get back into this episode.

Dr. Doug Mader:

All right. Where are we going to go with this? Number one. This is where your technicians are really important.

Dr. Andy Roark:

Okay.

Dr. Doug Mader:

Make sure your technicians are well-versed with this. You said you’re not 100% comfortable with exotics. Well, when you start getting into exotics, it’s a good idea to get a good technician that’s got a good background in it. Understands the biology and the husbandry.

Dr. Doug Mader:

Pay them really well. They’re going to save you a ton of money and make you a ton of money. The clients are going to love it, because they’re a source of information. They’re great support for veterinarians. We all need really good technicians.

Dr. Andy Roark:

Agreed.

Dr. Doug Mader:

You get the technician in there to talk to them and educate them. And then, you can go off and see your next client. They’re going to discuss the husbandry. We already talked about that. Temperature, diet, and light. Those are extremely important.

Dr. Doug Mader:

What can we do, medically? If the animal has pathological fractures, which oftentimes they do, because they have soft bones. Because of the calcium deficiencies. Analgesics. We tend to forget that animals hurt. If we see an animal that, let’s say, has a broken limb. And that’s not uncommon.

Dr. Doug Mader:

Even a broken back … I’m going to circle back to that in a second. But analgesics and NSAIDs. There’s nothing wrong with giving NSAIDs. I like Ketofen, personally. I know a lot of people use Meloxicam. I don’t know that you need to jump into the opioids, but I certainly use a lot of NSAIDs for these guys.

Dr. Doug Mader:

Supplements. Make sure they get calories. There’s a lot of good commercial herbivore and insectivore diets on the market. I don’t need to mention names, but we all know who the big players are. They’re excellent. They’re great diets. Vitamin D3 supplements. There are some very good commercial reptile vitamin supplements. But when you get them, make sure you get one that has D3 in it.

Dr. Andy Roark:

Okay.

Dr. Doug Mader:

You also want to give an oral calcium supplement. There are multiple different types and the best ones are the liquid ones. Unfortunately, they stopped making them. They pretty much all come as a tablet now, which you can have compounded through any of the compounding pharmacies into a liquid.

Dr. Doug Mader:

The only reason I say that is because, A, they’re easier to give. You can flavor them like a banana or something like that. B, the liquid forms tend to be more bioavailable. For instance, calcium glubionate. If you give it in the liquid form, it’s about 60% bioavailable.

Dr. Doug Mader:

Whereas calcium gluconate is only around 10% to 20% bioavailable. Give a good calcium supplement that the owner can give. If they try and give the calcium supplement and the patient fights it, we both know the owner’s not going to give it.

Dr. Andy Roark:

Yep.

Dr. Doug Mader:

Okay. Analgesics, if needed. Calcium supplements, absolutely necessary. Vitamin D3 supplement, absolutely necessary. If the animal has some pathology … Let’s say, it’s got a long bone fracture. Like a femur or humorous. Put a splint on it.

Dr. Doug Mader:

A wiggling bone is very painful. And these splints shouldn’t be big and bulky. A simple paper tape splint around the humorous or the femur or the distal limb really makes that animal comfortable by immobilizing the fracture. And it can take them six to eight weeks or more to heal.

Dr. Doug Mader:

One of the other things that works really well too, is you take them out of the cage or get a smaller cage and limit their mobility. In other words, you don’t want that bearded dragon feeling better, and then crawl up a rock, and then slip and fall down and re-injure itself. Limit their mobility.

Dr. Doug Mader:

Oftentimes, they’ll put them in a smaller terrain until they’re healed. Now, I just want to bring up the chronic case. You’re going to have some of these, where you have got the gold star client that does everything Dr. Andy tells them to do. They worship you. Everything you say, they write it down. They go home and they do it and that animal is still not getting better.

Dr. Doug Mader:

Chronic nutritional secondary hyperparathyroidism results because when the calcium levels drop … I won’t go too deep into physiology. The parathormone level, PTH, increases. That’s an emergency response by the body to make sure that there’s enough circulating calcium in the blood.

Dr. Doug Mader:

Because you need that for nerve conduction. Things like heartbeat, which is important. And so, the body will sacrifice the calcium in the bone, mobilize it so that it’s circulating and ionized. To keep the nerves moving, the brain functioning, the heart functioning and things like that.

Dr. Doug Mader:

But what happens is parathyroid hormone is extremely powerful. And the only thing that can turn it off is elevated calcium levels or elevated calcitonin levels. Calcitonin will shut off the parathyroid. Completely cut off parathyroid production from the brain.

Dr. Doug Mader:

In human medicine, they use something called salmon calcitonin. Miacalcin is the trade name. In these chronic cases, where you do everything right and the client does everything right. The animals are still … Their bones are staying like Gumby. They’re not getting better.

Dr. Doug Mader:

You need to break the parathyroid hormone influence. Salmon calcitonin does two things. Number one, it’s a powerful bone analgesic. It’s used a lot in women with osteoporosis that get lordosis and spinal fractures and they’re an intense pain. Salmon calcitonin takes that pain away. Number two, and this is the biggie, is that salmon calcitonin is a PTH antagonist.

Dr. Doug Mader:

And so, you can give all the vitamin D, all the supplements of calcium you want. That PTH is still being produced, because the body thinks it’s in crisis until you give the salmon calcitonin. And then, all of a sudden, it shuts off. Just like that. Literally, you will see a difference in a week or two.

Dr. Andy Roark:

Wow.

Dr. Doug Mader:

The only downside of it is it’s very expensive, because it’s a human drug. But if you get those chronic cases, where the client wants to do everything?

Dr. Doug Mader:

Salmon calcitonin is going to be the savior. The doses are in Carpenter’s book and you can find it in my book. It’s everywhere. But anyway, that’s the last therapeutic I’d recommend.

Dr. Andy Roark:

Right.

Dr. Doug Mader:

Let’s just talk about a couple other things. Did you have a question?

Dr. Andy Roark:

No, I was going to ask … Generally, we talked about if you’ve got a long bone fracture. Six to eight weeks in healing. We talked about these chronic cases. How long should I … I like to set realistic expectations for the pet owners as well.

Dr. Andy Roark:

When are they going to start to notice improvement in the symptoms in their bearded dragon? For example, if we can correct the temperature problems. And I’m making sure that we are controlling pain, and that we’re getting good calories.

Dr. Andy Roark:

We’ve got some D3 supplementation. Some calcium supplementation. We’re doing all of the things. How quickly do we expect for pet owners to see significant improvement? I don’t want them to have wildly out of whack expectations.

Dr. Doug Mader:

I’m glad you asked that. I was going to get to it, but I’m glad you brought it up. Because I’m sure others are thinking the same thing. Remember, these are reptiles. They do everything slow.

Dr. Andy Roark:

Right.

Dr. Doug Mader:

You might treat a dog or a cat or a bird and you’ll see some improvement in a couple or three days. It’s not going to happen that fast in a reptile. You got to give it at least four weeks.

Dr. Andy Roark:

Okay.

Dr. Doug Mader:

I tell clients, “Four weeks and you’re going to start seeing a turnaround. Don’t get frustrated a week and a half, two weeks down the road and think nothing’s working. It probably is. You’re just not seeing it. Please, trust me. Follow the instructions. In a month, we’re going to be doing a happy dance.”

Dr. Doug Mader:

Full healing? Depending on how bad it is and depending on how advanced it is when you catch it … Three, maybe six months. But most of these animals come completely back to normal. Some of them will have some deformities. They may have some angular limb deformities from their long bones.

Dr. Doug Mader:

Sometimes they get that bowing in the jaw. They call it rubber jaws. That’s the term that came from primate medicine years ago. But they’re fine. They have a quirky look to them, but they’re still great pets. They’re fully functional. Excuse me. I do want to mention a couple other things too.

Dr. Andy Roark:

Sure.

Dr. Doug Mader:

And that is one of the knee-jerk responses that a lot of veterinarians give. This goes, in the literature, back literally to the 70s. You know how it is.

Dr. Doug Mader:

When something’s in the literature that’s correct, it’s really hard to get people to buy into it. You put something in the literature that’s wrong? Everybody believes.

Dr. Andy Roark:

That grabs them.

Dr. Doug Mader:

It’s like wildfire. Back in the 70s, it was published that, when these animals come in, you can put them on injectable calcium. Because it increases their calcium quicker.

Dr. Doug Mader:

Absolutely, positively not. Think back when you were a kid and you fell off the bike and broke your arm. Did the doctor give you injectable calcium?

Dr. Andy Roark:

No.

Dr. Doug Mader:

No. They sent you home on a quality diet, a cast, and some good vitamins and you’d get better. Same thing. You don’t use injectable calcium unless you have a pregnant bitch in tetany, a cow with milk fever. Or if the bearded dragon comes in, and it is in fact in tetany, where the whole thing is twitching like this … You might want to put him on a very controlled dose.

Dr. Doug Mader:

Seven units per kilogram per hour of calcium until the tetany resolves. And then, you switch to oral. Injectable calcium is emergency, life-saving only. It is not for treating broken bones or chronic osteomalacia. I wanted to make sure. That’s important. Because people still do it.

Dr. Doug Mader:

The other thing too is don’t throw Baytril at them. They come in and they’re not eating. “Let’s put them on Baytril. Just in case.” No. Antibiotic stewardship. We don’t want to be just throwing antibiotics out there. Unless you can see that this animal has some evident infection, don’t just give them antibiotics. They don’t need it. This is a husbandry issue. It’s a supplement issue.

Dr. Doug Mader:

Just to wrap this up. Again, most of these cases in the signalment that you presented are going to be nutritional or they’re going to be husbandry. 90% of the homework is going to be the owners following your instructions and correcting the problems on their end. You’re just helping them along.

Dr. Doug Mader:

They will do really well. Even some of these lizards that come in with pathological spinal fractures. Reptiles are neat. That’s why they’ve been around for so many millions of years. They have spinal ganglia. You can take the lizards back and cut it right in half and the spinal ganglia will allow them to walk.

Dr. Doug Mader:

Their front feet do this. The back feet may do this. In other words, the back feet and the front feet don’t talk to each other. But they still manage to get around. Because of the spinal ganglia, where they’re located, they can still defecate and urinate.

Dr. Doug Mader:

Just because it has a broken back, don’t say, “This animal is going to have to be euthanized.” If the owner wants to keep trying … Man. As a veterinarian, we owe it to them to hold their hand and get them through this. Because a lot of these reptiles will get through it. You just have to be patient.

Dr. Doug Mader:

That’s what a lot of people … They don’t have the experience enough to know that, “Hey. Let’s hang in there for three or four months. This animal will probably turn around.” I want to end with that on the happy note. The majority of these animals will do well, if you identify and correct the problems.

Dr. Andy Roark:

That’s amazing. Thank you so much for that. Let me ask you one more quick question when we talk about pain control. I thought that was really a great point. Things that people may not think about that are truly important.

Dr. Andy Roark:

If we’re going to see slow resolution of symptoms, we’re looking at four weeks. Things like that. How long do you manage pain control? Is that also a four-week process? Things like that? Walk me through some analgesia during this process. Because I don’t want to overdo it, but I also don’t want to under-serve them.

Dr. Doug Mader:

That’s a super good question. Because anything you give an animal, there’s a potential side effect. In long-term use of NSAIDs, you worry about liver disease, kidney disease, potential GI ulcers. That’s a good question.

Dr. Doug Mader:

That’s where I think you, as the eyes on the ground, when that animal starts looking more BAR. The owner’s going to be able to tell that, because they see that animal every day. And you’ll check it on re-checks. And then, I usually say eating.

Dr. Doug Mader:

When they start eating again, oftentimes, they’re feeling good enough that they can stop the analgesics. But clearly, if they start eating … You stop the analgesics and eating stops? You may want to put them back on it. But I oftentimes use appetite as one of my gold standards. That’s a great question. Thank you.

Dr. Andy Roark:

No, I appreciate it. Doug, where can people find you online?

Dr. Doug Mader:

Well, I have a website. It’s dougmader.com. I have a public Facebook page. It’s Douglas Mader on Facebook. From there, you can reach out. If you have questions, you can email me. And I’m pretty good about getting back to people. Feel free to reach out, if you need some help.

Dr. Doug Mader:

You know what? Andy, I just want to say thanks again for having me on. I think we have one of the greatest professions in the world. I hear a lot of people say, “I would never do this again.” I’ll tell you what. I’ve been doing it for nearly four decades. I would do it all over again. Starting tomorrow.

Dr. Andy Roark:

I love it.

Dr. Doug Mader:

I love what we do. That human-animal bond is so special. Anything we can do to keep that thing going, and your podcast and helping educate veterinarians, technicians, and then the pet owners is the way we do this. Thank you.

Dr. Andy Roark:

Thank you, my friend. And that is our episode. Guys, that’s what I got for you. I hope you enjoyed it. I hope you got a lot out of it. I got a lot out of it. I don’t remember the last time I took as many notes as I took on this episode.

Dr. Andy Roark:

Anyway, thanks again to Dr. Mader for being here. Man, that guy is incredible. Anyway, that’s enough of me fanboying over Doug Mader. You guys take care of yourself. Have a wonderful week and I’ll talk to you later.

Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram

Tasha McNerney CTV VTS CVPP joins us to discuss the case of Hercules Mulligan. a 4 yo MN Domestic Shorthair who cannot urinate. That’s right… This poor guy has a urethral obstruction and will need anesthesia and pain control STAT! What are the top tips and tricks for handling these cases? What mistakes do doctors and technicians want to make sure to avoid? Let’s find out!

You can also listen to this episode on Apple Podcasts, Google Podcasts, Soundcloud, YouTube, or wherever you get your podcasts!

LINKS

Sacrococcygeal Block Demo: https://www.youtube.com/watch?v=KhAN4SavVzg

Think Anesthesia: https://www.thinkanesthesia.education/

Retain Your Team – Speak the Languages of Appreciation in Your Workplace: https://unchartedvet.com/product/appreciation-languages-101/

What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Tasha McNerney obtained her CVT in 2005 and has worked clinically in the areas of anesthesia and surgery ever since. Tasha obtained her CVPP (certified veterinary pain practitioner) designation in 2013 and became a veterinary technician specialist in anesthesia in 2015.

Tasha has been a featured speaker on various anesthesia and pain management topics at several international veterinary conferences. Tasha is the author of many articles and blogs on anesthesia and pain management related topics.

In 2013 Tasha created the Facebook group Veterinary Anesthesia Nerds, which has over 65,000 members taking part in education and exchange of ideas from all over the world!

Tasha is crazy and bought a 1920’s fixer upper and is now obsessed with home improvement tutorials on YouTube. She lives in Philadelphia with her husband, son, one perfect cat, and one jerk cat. Trust me that cat is a jerk.

EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:

Welcome, everybody, to The Cone of Shame veterinary podcast. I’m your host, Dr. Andy Roark. Guys, I am here today with the original anesthesia nerd, the one and only, Tasha McNerney, and she is fantastic as usual. We are talking about the blocked cat and running effective anesthesia and pain control in those emergency cases. Guys, we see a lot of these in the vet clinic. They are an emergency, and we want to do right by our patients as far as making them as comfortable as possible, while we do uncomfortable things to save their life. Gang, let’s get into this episode.

Kelsey Beth Carpenter:

(Singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to The Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:

Welcome to the podcast, the one and only, Tasha McNerney. How are you?

Tasha McNerney:

I’m good. How are you? How is everything?

Dr. Andy Roark:

Things are good. Rolling into the spring. Yeah, exciting times around here. Getting close to the summer break. The kids are starting to make plans for what they’re going to do this summer. I got a load of mulch from my garden and that makes me happy. So, that’s-

Tasha McNerney:

You know-

Dr. Andy Roark:

[crosstalk 00:01:29].

Tasha McNerney:

You’re an adult when you’re excited about mulch, right?

Dr. Andy Roark:

Oh, yeah.

Tasha McNerney:

And then, you’re like, “What type of mulch? Are you a red mulch person? Are you a brown mulch person?”

Dr. Andy Roark:

Oh, it’s-

Tasha McNerney:

“Are you a black mulch person?”

Dr. Andy Roark:

It’s brown mulch, yeah.

Tasha McNerney:

Okay, yeah. So…

Dr. Andy Roark:

It’s the double brown mulch. Yeah, it is. Yeah, the hummingbirds will be back soon. And that is where I am in my life.

Tasha McNerney:

I mean, listen, my husband is out there feeding the birds every morning and he is very concerned about the birds. He likes to watch the birds. He likes to tell me how many birds are in the backyard, whether or not there’s a chipmunk with the birds, if he saw a rabbit outside. These are the things that we get excited about now, right? Yeah.

Dr. Andy Roark:

Yeah. You married-

Tasha McNerney:

[crosstalk 00:02:09].

Dr. Andy Roark:

The cat.

Tasha McNerney:

Yeah, I did. I did marry a crazy cat lady and that’s totally fine.

Dr. Andy Roark:

Oh, god.

Tasha McNerney:

I love him. But yeah, he’s excited about birds, and choosing a high quality bird seed is very important. And we used to be cool. We used to go out on Saturday nights. And now, we’re like, “Um, so Righteous Gemstones and researching bird feeder option?” “Yes.” That’s a Saturday night.

Dr. Andy Roark:

Yeah. Okay, we need to spend more time together because one, Righteous Gemstones for the win. I love that-

Tasha McNerney:

Oh, 100%.

Dr. Andy Roark:

It’s a guilty pleasure show. I love that show. And then number two, this was the first time in my life I have ever walked into a Lowe’s and looked at the different bird seeds and thought, “Ugh, who would feed that?” I never had a thought like that in my life. I’m like, “What has the pandemic done to me? It has made me…” I’m like, “Ooh, this is the cheap stuff. I’m not feeding this.” What have I become? Good God. All right, let’s ride this show. Let’s talk about other things besides bird seed and Righteous Gemstone. Let’s talk about blocked cats.

Tasha McNerney:

Yeah.

Dr. Andy Roark:

The other part of the trifecta of things that are super cool. All right. I have a case. Tasha, first of all, for those of you who don’t know, you are the founder of Veterinary Anesthesia Nerds, which is a Facebook group and also a conference now and so many things. For anyone who’s interested in anesthesia, you should really check out Veterinary Anesthesia Nerds. What is the best place for people to find information on that group?

Tasha McNerney:

So our Facebook group is probably where we are the most active, where we talk about cases every day and run through cases, equipment, et cetera. We also have a website that you guys can check out. And then, we have since partnered with dvm360. So a lot of our content and articles from the administrators, myself, Stephen Cital, Darci Palmer, all VTS in anesthesia, we have a lot of articles on dvm360 that you can find there as well for different anesthesia topics.

Dr. Andy Roark:

That’s awesome. All right, cool. I’m going to toss you a softball today because I just-

Tasha McNerney:

Oh, great.

Dr. Andy Roark:

Want to make sure that I am up on my game. Yeah. I just want to make sure that I’m doing all right. It’s one of those questions just [inaudible 00:04:18] make sure that nothing has changed in how I’m doing this. Make sure that I’ve got all the pearls that I need to do a really good job. I have a four year old male, neutered, domestic short hair named Hercules Mulligan and he is obstructed. He’s come in, he was straining in the litter box. His owners who are huge Hamilton fans brought him in and they were like… He’s crying. He’s in the litter box.

Dr. Andy Roark:

I feel his belly. I know immediately what’s going on. This guy is obstructed. I’ve pulled some blood on him. I’m checking my electrolyte levels, making sure that nothing is super wonky there, and he seems to be okay. Aside from starting IV fluids, things like that, I need to go ahead and get this cat unblocked, and I don’t want this to hurt. And I also want to get him pliable and easy to work with. And so again, he is an otherwise healthy, young to middle aged male cat. Help me with my anesthesia, analgesia protocol here, so that he is comfortable and I can do what I need to do as quickly as possible.

Tasha McNerney:

Sure. So first of all, anesthesia, I mean, it’s definitely about drugs, but it’s not all about drugs. And we know with some of the more kind of progressive ways, at least in the last 10 years and what I have seen and probably you’ve seen in practice as well, is that we don’t just go into drugs. We want to take stock of kind of where the patient is at, kind of where with their own fear and anxiety. So how scared is the cat, right? So, how upset is he with being at the vet? How fearful is he? How reactive is he? And that is really going to play a lot into what I do next. If he is very fearful-

Dr. Andy Roark:

Okay, I like this a lot.

Tasha McNerney:

If he is very fearful and painful, then I’m probably going to go with some IM sedation. I don’t want to take this cat that is potentially again, very fearful, very painful obviously… If anyone here has ever went on a very long car ride and had just an overextended bladder that’s getting very uncomfortable, if you think about that times 10, this is what our patients are experiencing. So, very uncomfortable. I don’t want to take that patient and then have to have our support staff kind of sit on or muzzle or wrestle with this cat to try to get an IV catheter into them.

Dr. Andy Roark:

Right.

Tasha McNerney:

Stress is going to be the enemy for these patients. I mean, any cat that potentially has any underlying cardiac issue, with potentially a hyperkalemic patient as this, we don’t want to stress them. So, stress is our enemy. So, let’s take stock. If he is a super love bug cat, and he is going to let me put an IV catheter in and facilitate that without an IM injection or IM sedation, great. And then, we can follow up with some IV analgesics, anesthetics, et cetera. But if he is saying, “No, you guys. I’ve had enough. I’ve already had a crap day. I don’t feel good. You’re not going to twist my arm to put an IV catheter in. No,” then-

Dr. Andy Roark:

Right.

Tasha McNerney:

I’m probably going to sedate. And I love this option because just sedate the cat, right? Just give them drugs. We have lots of great drug options that we can give them. And first off, we want to look at our analgesics. Certainly, if you have a pure mu-opioid in your practice, my favorite is methadone. But if you guys have hydro, you could consider hydro. Now, just remember, you might see some vomiting with the hydro, but if that’s your heaviest hitter, go with that. I like a methadone combination. Again, if you don’t have methadone and you’re like, “Oh man, I only have butorphanol,” okay. Even though that’s more of a sedative than an analgesic, go with that. So, we want to combine an analgesic with a sedative.

Tasha McNerney:

Now sometimes, as people know and if they’ve ever listened to me talk, they know that one of my favorite sedative analgesic combinations is opioid plus dexmedetomidine. This is not the patient I would probably choose for dexmedetomidine because again, we don’t know exactly… Unless you’ve taken blood and evaluated his potassium levels, we don’t know where that’s at. I don’t know if he’s hyperkalemic and bradycardic and potentially already having some arrhythmias because of the urethra obstruction.

Dr. Andy Roark:

Got it.

Tasha McNerney:

So, let’s just assume maybe he is and I just want to be very careful. So I’m going to take dexmedetomidine off the table. In a younger animal, a lot of times, especially if they’re already stressed, I might… Or sometimes, I might combine midazolam or benzodiazepine. But in a younger animal that is already stressed, fearful, aggressive, et cetera, I’m probably not going to utilize midazolam because our benzodiazepines can kind of give them that excitatory reaction. And it’s even more pronounced in younger patients. That’s why for a lot of the anesthesiologists that I work with, if an animal is under three years old, we’re usually not hitting them with a benzodiazepine because it’s going to ramp up that excitatory phase.

Dr. Andy Roark:

Got it.

Tasha McNerney:

Especially if you have a stressed cat, nothing’s going to take them through the roof like a benzodiazepine. So, I’m taking that off the table too. So, what I’m left with is a huge [crosstalk 00:09:08]-

Dr. Andy Roark:

Got it. You’re taking away all of my favorite things.

Tasha McNerney:

I’m sorry. Listen, don’t worry. We have other options.

Dr. Andy Roark:

I’m like, “Oh, I’m running out of…” Yeah, my medicine cabinet’s looking kind of thin at this point, Tasha. Where we going?

Tasha McNerney:

So, we have other options and the opioid is going to be kind of your heavy hitter. And if you want to, whatever opioid you decide to use, I would just go a little higher on your dosing. And then, if you have alphaxalone in your practice, this is where alphaxalone can really shine because alphaxalone can be utilized IV or IM. We will usually combine the alphaxalone together with an opioid and then give that IM. So if this is a spicy kitty who we want to be very cardiac friendly to, we usually combine opioid plus alphaxalone IM, let them sit in a nice, calm, quiet environment. And that means don’t put them next to a dog that’s recovering from surgery and potentially-

Dr. Andy Roark:

Right.

Tasha McNerney:

Howling. Don’t put them next to other cats that could stress them out. If you can, put them as isolated and as quiet an environment as possible while they kind of calm down, let those drugs start simmering and working. Now, once those drugs have taken effect or while the drugs are taking effect, I should say, that’s the time that your staff should be gathering the supplies that are needed to unblock this cat.

Dr. Andy Roark:

Right.

Tasha McNerney:

Now, whether or not you guys like a red rubber, or you like a Foley, or you like a Tomcat, personal preference, just have a list of things together so that your staff can work quickly. I always advise that I’m a big fan of checklist. I love an anesthesia checklist, I love a surgical checklist. So if you have a little page in your nursing binder that would just say, “Hey, for urethral obstruction, this is what I want you guys to get out and ready.”

Tasha McNerney:

So that way, while that cat is simmering on its drugs, you know “Hey, I’m going to go pull the fluids. I’m going to go pull out the supplies I need for a sacrococcygeal block. I’m going to go pull out everything the doctor might need to facilitate this unblocking, make it go as smooth as possible.” So, use that time while the cat is simmering on its drugs and its analgesics to gather everything. So that way, you’re not running around and kind of… With a spicy cat and a painful cat, it’s always kind of a race against time with them, right? How much can I get done before their stress catecholamines override the drugs I’ve given them? And then now, I have to add in more.

Dr. Andy Roark:

Hey guys, we’re going to jump in with a couple of quick announcements. First off, if you have not head over to drandyroark.com recently and signed up for the Dr. Andy Roark newsletter, you’re missing out. What’s on the podcast is in our new newsletters. I like to write letters in our newsletters. We’ve got some great article stuff that comes out there. It is all really good stuff, and it’s totally free, right in your inbox. So, drandyroark.com. Sign up for the newsletter. Also, on May 21st, we have a fan-freaking-tastic workshop over at Uncharted Veterinary Conference. It is a virtual workshop. It is called, Retain Your Team : Speak The Languages of Appreciation in Your Workplace, with the one and only, Dr. Tracy Sands. Guys, this is at 2:00 PM Eastern time, 11:00 AM Pacific. It’s a two hour work shop on May 21st. It is free to Uncharted members. It is $99 to the public.

Dr. Andy Roark:

If you are trying to get your staff to stick around, if you’re trying to get your staff to be engaged, if you’re trying to get your staff to feel like their work matters, and you keep buying donuts, but it’s just not having the same effect that it used to, it’s time to do something different. It’s time to learn about the languages of appreciation. We have a self-assessment, so you can look and see how you’re doing and how you can make changes going forward. Guys, that’s how we roll. May 21st, 2:00 PM Eastern, 11:00 AM Pacific time. Head over to unchartedvet.com and click on Upcoming Events and you’ll get all taken care of, okay? Now, let’s get back into this. Talk to me a little bit about alphaxalone IM. That’s not a route that I’ve used a whole lot. So, give me just a general idea of what are common side effects? What amount of time are we talking about? Just help me feel out what to expect when I go this route with say, a methadone or a hydromorphone mixed with some alphaxalone.

Tasha McNerney:

Sure. So alphaxalone is a pretty great drug, and then we know that we use it as an induction agent. Anesthesia people like to call it propofol 2.0, because it gives you the same effects of propofol. And when I say same effects, we are… It’s great induction agent. Alphaxalone in itself is a neuro steroid molecule, works in the GABA pathways, and it is going to function similarly to propofol. And when I say that, you also are going to get hypotension the way you would with propofol if you give it in a big bolus. You also can see apnea the way you do with propofol if you give it in a big bolus. But if we’re talking about via the IM route, I like to think of it just kind of as the cream in that Oreo cookie, bringing the opioid, smoothing everything out together. Yes, I do use a lot of food references in a lot of my lectures. So, [crosstalk 00:14:03]-

Dr. Andy Roark:

No, I love it.

Tasha McNerney:

And your alphaxalone with the opioid together kind of makes this nice combination for the patient, because if we just kept relying on all opioid, we know that opioids by themselves are not usually sedating. And the amount of volume or migs per kig we’d have to give to really sedate a cat that’s already painful and spicy is a lot of opioid. And then, we could be seeing opioid side effects, right? Bradycardia, et cetera, which we don’t want. So if we combine our opioid with an alphaxalone IM, alphaxalone’s water soluble. So a much better option than something like diazepam, which hopefully people are not giving diazepam IM anymore. But you can combine these two things in the same syringe, opioid plus alphaxalone, and give that. Usually for cats, we are doing one mig per kig, right?

Tasha McNerney:

Sometimes two, but usually, one mig per kig of alphaxalone IM together with your opioid of choice. And you give them about 10 to 15 minutes. And I’m not saying that they are all the way out in the same way that they would be maybe with a dexmedetomidine or ketamine combination. But again, we’re trying to avoid those cardioactive drugs in this patient. So, they might be out enough that you can facilitate smooth IV catheter placement. And then, once you have a IV catheter placed, you can top off with more alphaxalone, give them flow by oxygen, put all your monitors on, and then release the sacrococcygeal block and get ready to go.

Dr. Andy Roark:

Yeah, cool. Talk to me a little bit about the sacrococcygeal block. Just give me some best practices tips. How do I want to set myself up for success with this?

Tasha McNerney:

Oh man, this is one of my favorite blocks to talk about. I like to talk about a lot of blocks, but if anything, the reason I really love sacrococcygeal blocks is that it doesn’t have to… You don’t have to work in a specialty practice or university. This is something that every general practice, you already have the supplies on your shelf to do this block. And it is going to be a game changer when it comes to urethra obstruction cats. So the nice thing about the sacrococcygeal block is it is just 25 gauge, 5/8 inch needle, a 1cc syringe. You want to keep this clean as possible. So if you can utilize sterile gloves, that is great. And just stuff to scrub up the area. And it’s kind of, again, dealer’s choice with the drugs. Some people like to use lidocaine. Some people like to use bupivacaine. I personally, in this patient in particular, will utilize lidocaine. Little more cost effective. And for this particular patient, lidocaine is going to last for a couple of hours.

Tasha McNerney:

I could utilize bupivacaine and desensitize that area for the six hours that bupivacaine could. But for most of these patients, once we relieve the obstruction, a lot of the pain will go away. And the nice thing about utilizing a lidocaine or a sacrococcygeal block is it is one of the very few drugs or route of drug administration that’s going to completely cut off those signals going to the brain, right? So we know, if you guys have ever had local anesthetic at the dentist or et cetera, if you’ve ever… Childbirth and had an epidural, you know that it cuts off those signals going to the brain. So that way, when your doctor lifts the cat over or puts the cat’s feet forward, or however their technique is, once they start trying to extrude that penis… With a sacrococcygeal block on board, it’s desensitized and the penis will often just come out of the [inaudible 00:17:35]. There’s no fiddling with it. There’s no kind of pulling on it, which causes a lot of irritation and inflammation.

Dr. Andy Roark:

Right.

Tasha McNerney:

So we see a huge reduction in irritation and inflammation, a much faster speed of unblocking, and overall less anesthetic time for the patient. So for us, a sacrococcygeal block is very cost effective and very effective when it comes to pain management.

Dr. Andy Roark:

All right, that makes total sense. All right, good. I feel like I’m really set up well for success here. What pitfalls do I need to look out for? Are there things that you see people get wrong? Are there mistakes that people make any? Any common trips or traps that I should look out for?

Tasha McNerney:

So for block cats, sure. Right? I think everybody’s terrified of tearing the urethra or something worse which certainly can happen. So, I would say that if you are going to do anything… I’ve seen a couple not great things happen. And usually, it’s when people are over aggressive or utilizing… The one I have seen is utilizing a stylet, kind of a metal stylet to go inside the red rubber-

Dr. Andy Roark:

Oh, yeah.

Tasha McNerney:

To give it a little more oomph. But the problem is you give it too much oomph and it goes in and I have seen urethral-

Dr. Andy Roark:

Ew.

Tasha McNerney:

Tear that way. So, just be careful if you’re utilizing anything like that. And these cases can be really frustrating. If you feel like you are trying and you’re not getting anywhere, and the patient’s tissue is just getting more inflamed, take a step back, ask a colleague if they want to step in. I think that has been really the biggest thing for me as a technician. Since I’m usually monitoring the anesthesia and I’m watching the clinicians do this, if they’re getting more frustrated, they’re going to put more pressure on that tissue. It’s not a great experience for anybody. So if you have a colleague, you just say, “Hey, I’m not having any luck with this. Do you think there is a technique?” Because again, everybody goes to vet school in different places and learns from different people. So, I have one doctor who really likes the Tomcat catheters. I have one doctor who really likes the olive tip catheters. So, there might be a technique that you haven’t learned or you haven’t thought of. So instead of keep messing with that tissue, phone a friend. Ask somebody to help.

Dr. Andy Roark:

Yeah. A lot of us not even… When you went to vet school, a lot of it was just, what kind of day are you having?

Tasha McNerney:

Oh, yeah.

Dr. Andy Roark:

That’s the classes. Some days, it’s like, “I just don’t have it some days,” and some days I can throw it across the room and hit exactly where it needs to go. But yeah, I don’t even think it’s often your training or your style. Just some days, it’s just not your day. And it’s better just accept it and phone a friend before you end up in a hole. Awesome. Any final pearls? Anything like that? Yeah, any last words of advice?

Tasha McNerney:

No. I love these cases and I think a lot of clinicians really love these cases as well, because you can see an immediate-

Dr. Andy Roark:

Oh, yeah.

Tasha McNerney:

You can see such a difference in 24 hours-

Dr. Andy Roark:

Super.

Tasha McNerney:

With these patients.

Dr. Andy Roark:

Super rewarding, yeah.

Tasha McNerney:

But for technicians, what I tell technicians is, “Use the time that the animal is simmering on its drugs to really get everything together. And don’t forget about your calcium, [glutamine 00:20:48] and your insulin. Just always have that ready and available, so when you run that blood work, if you happen to see a potassium of, I don’t know, 10, you’re ready to go with some intervention.”

Dr. Andy Roark:

Good, that’s so awesome. We talked at the very beginning about Anesthesia Nerds. Tasha, do you have favorite anesthesia resources online, outside of Anesthesia Nerds?

Tasha McNerney:

Oh, yeah. So I think that, pun intended, the Think Anesthesia website is actually a really great website and it offers a lot of free resources. So if you’re thinking about getting some CE and you don’t have it in your CE budget to actually go to a conference or even sign up for a webinar that may cost money, Think Anesthesia, which was brought about by some of the anesthesiologists at [Durox 00:21:32], is a really fantastic website. They have webinars and articles on anesthesia recovery, anesthesia induction, anesthesia for rabbits, all kinds of stuff. So, that’s a really nice resource that I like.

Dr. Andy Roark:

That’s awesome. I’ll put a link to that in the show notes. Thank you so much for being here. I always appreciate your time.

Tasha McNerney:

No problem. Thanks for having me.

Dr. Andy Roark:

And that is our episode guys. I hope you enjoyed it. I hope you got something out of it. If you are on the Facebook, consider checking out the Veterinary Anesthesia Nerd group. Those guys are so great. It is awesome to see people who are passionate about a thing, sharing their passion. And that is that group. Gang, take care of yourselves, be well. I’ll talk to you soon.

Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram