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Medicine

HOF: Anesthesia Crash Cart Course

December 7, 2023 by Andy Roark DVM MS

Dr. Andy Roark dusts off this Hall of Fame episode in which he discusses the essentials of anesthesia crash carts with Veterinary Anesthesia Nerd, Tasha McNerney. Together they talk about what tools should be in your anesthesia crash kit and what kind of common pitfalls they’ve seen in practice.

Cone Of Shame Veterinary Podcast · CoS HoF – 242 – HOF: Anesthesia Crash Cart Course

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

LINKS

Veterinary Anesthesia Nerds: https://www.facebook.com/groups/veterinaryanesthesianerds/

RECOVER Resources: https://recoverinitiative.org/category/resources-and-tools/

Upcoming Webinar (Free RACE CE): https://drandyroark.com/headcases

Dr. Andy Roark Resources 

Dr. Andy Roark Swag

ABOUT OUR GUEST

Tasha McNerney is a Certified Veterinary Technician from Pennsylvania where she works as a educational consultant and relief anesthesia technician. Tasha is the founder of the Veterinary Anesthesia Nerds, while also a Certified Veterinary Pain Practitioner and board member of the International Veterinary Academy of Pain Management (IVAPM) to educate the public about animal pain awareness. In fact, Tasha was the thought leader behind the now celebrated “Animal Pain Awareness Month” within the veterinary industry. Tasha became a veterinary technician specialist in anesthesia in 2015. Tasha loves to lecture on various anesthesia and pain management topics around the globe and was previously named VMX Speaker of the Year.


EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary podcast. I’m your host, Dr. Andy Roark. Guys, I am pulling one out of the vault for you, just blowing the dust off of it. This is a Hall of Fame episode with my good friend, the one and only Tasha McNerney, the original anesthesia nerd. We are doing the anesthesia crash cart crash course. It’s just a box of pearls. That’s what it is. It’s just knowledge, pearls, and I just put ’em all together in this box and here you go. From me to you. Happy holidays. It is a great episode. It is one of our most popular episodes of the last year, and you’re going to see why when you check it out, even if you heard it when it came out, it’s time to brush it up again. There’s so many mind gemstones here that you went through and you put some in your brain the first time, and I promise you there’s a lot more room. You’re ready for other ones. Now you’re ready for the next level of mind stones that go in. I don’t know what this metaphor is, but I think you’re just going to enjoy this episode. Let’s just do 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, Tasha McNerney. How are you?

Tasha McNerney:
I’m good. How are you?

Dr. Andy Roark:
I’m so good. It’s so good to see your face again. You’re one of my favorite people. You and me go way back. I’m like way back, way back. You were here visiting my house when the pandemic hit, and I’ll never forget you and I started the pandemic together.

Tasha McNerney:
Yes, yes. I have great memories of visiting four different stores, looking for canned goods and then finally buying all the beans at a CVS in some random South South Carolina town. Still have those beans.

Dr. Andy Roark:
I still have those beans a hundred percent. I’m like, these are my survival beans.

Tasha McNerney:
Yeah, well you save them.

Dr. Andy Roark:
My wife, she was like, “we’ll never eat these.” And I’m like, look, as long as they’re there, I’ll sleep well at night, but as soon as you throw away my emergency beans, I’m going to be like, what are we going to do if society ends? Yeah.

Tasha McNerney:
Yeah. It was a good time.

Dr. Andy Roark:
I felt, you know what? When the world went sideways, you and I took action. That’s all I’m going to say. And most people, a hundred percent did not, but we did.

Tasha McNerney:
No, people were like, is this happening? And we both looked at each other and be like, oh, we better stock up this pantry. Even though it wasn’t my pantry. I was like, I’ll help you stock up this pantry. You were with me. I had gotten a call from my husband at home saying, everything is off the shelves. It’s kind of pandemonium here. And at that same CVS, I bought two boxes of pasta and took them back in my luggage with me because I was so worried that I wouldn’t be able to find pasta when I went home. So yeah.

Dr. Andy Roark:
Oh man. That’s great to be with an anesthesia specialist because when the world goes haywire, they take action and I felt like that was instinctual for you.

Tasha McNerney:
Oh, 100%. I think I always joke with the anesthesia is that we are very cool, common, collected. When everything is crashing in the ER or in the OR wherever we are, it’s very much, okay, here’s the problem, where do we go next? Alright. And we start this kind of checklist. It’s very much cool, calm and collected in anesthesia. And the joke is that we’re dead on the inside. And sometimes I would agree with that in that we’re not going to be the people freaking out like, oh my God, everything is crashing. Go get this for me. Really that actually with me that things are real bad if I get very calm and monotone. And if I say, okay, what I need you to do next is turn off that vaporizer and can you hand me the epinephrine? Okay. Things are going down. Things are going down.

Dr. Andy Roark:
Yeah. Oh man. Yeah, you are a bit dead on the inside though. That’s just inside baseball from an old friend.

Tasha McNerney:
Yeah. And you know what? Listen, I got a therapist. We’re working on it. We’re good.

Dr. Andy Roark:
I think a lot of people could stand to be more dead on the inside. I think it would probably be, we all know a people who should be a little bit less alive inside. It would help them.

Tasha McNerney:
Yeah. Just calm down.

Dr. Andy Roark:
Totally. Alright, for those who don’t know you, you are a veterinary technician, specialist in Anesthesia. You are the founder of the Veterinary Anesthesia Nerds Group. It’s a Facebook group, it’s a website, it’s a conference. This thing has grown to how many people are involved engaged with the Anesthesia nerds group now?

Tasha McNerney:
Oh, we have about 65,000 members around the world right now. Yeah.

Dr. Andy Roark:
It’s awesome. It’s super awesome. It’s super bonkers. And I could sit here and sing the praises of the anesthesia nerds. I’m all about practical education. I really like to learn stuff that I’m like, I’m actually going to use this. And that is what you guys are all about. So I really love it. I’m super glad that you’re here. I thought of you recently when I had a pet under anesthesia and I can’t remember why. It was an emergency of some sort. And I had this pet under anesthesia and it just kind of dipped there for a second. And so when you pause for a second and you’re like, is this going to be an issue? And then it kind of stabilizes and comes back out and I thought I could use a refresher on the crash cart. That’s exactly what I took away from that specific instance was it was an emergency that came in. I can’t remember what it was. It went under anesthesia to get fixed. And I thought, you know what? Let’s just freshen these skills back up. And so I wanted to get you in and just say, run through the crash cart with me real quick. Let’s do a hundred percent refresher on what’s in my crash cart, what’s it do, what do I need to know about it? And just make me feel like the dust has been blown off my crashing patient knowledge. Is that okay?

Tasha McNerney:
Oh yeah, let’s do it. So, ooh, there’s probably a lot to cover, but we’ll kind maybe put it into categories when you’re looking at your crash cart. And again, just want everybody to know that I’m talking about this in the context of an anesthetic crash cart, not necessarily your ER crash cart, which is probably going to be a little bit different, but when we look at our anesthetic crash cart or what we want to have in that top drawer of our anesthesia machine or on hand during any anesthetic event, that’s what I’m going to talk about here. That’s cool with you. All right. So first of all, any emergency, again, when I say to you, Hey, things are not looking good, can you turn off that vaporizer? And then one of the first things that I want you to do is pull out our real emergency drugs.
And when I say emergency drugs with anesthesia in mind when I’m talking about are our emergency things like atropine and epi and then our anesthetic reversals. So these are really the two big things in our crash cart. We know that we want to have atropine or anticholinergic that we will use in emergencies because it has a very fast onset, shorter duration of action than glycoparalate. But again, in an emergency, we want that fast onset. Now there’s some stuff, and I will let you guys listening at home do some research because I think this is very, very interesting. Looking at the newer research that has come out in the past couple of years asking, especially starting in human medicine, asking is there really any benefit to using atropine during a code or a CPR event? And the human medicine, human literature has actually found that there isn’t, and they actually don’t really use atropine anymore during emergencies.
And if you look at the newest recovery guidelines, they actually state that atropine is not necessarily beneficial, but they don’t know if it’s really going to do any harm either. So if you feel like you still want to keep that in your back pocket, you’re probably not doing any harm. But it’s a little different than we thought 10 years ago that we don’t necessarily know that it’s really doing a lot during our CPR events or our code events. But I still will get it out. And I will say that my anesthesiologist will still have us give it during an emergency. Our next is epinephrine, right? And that’s because we want that basic constriction. We want to make sure that our blood pressure stays tight. We want to make sure that we are delivering oxygen to the tissues to where it needs to go. So again, our emergency drugs, then we need to get rid of whatever anesthetic.
Again, if this is a true anesthetic emergency, we want to make sure that we have reversals in our crash cart to reverse every single drug that can be reversed. Now, most of the time with anesthesia, we are administering opioids. So that means that we need naloxone first and foremost in our crash cart. So if we have an opioid on board, we want to make sure that we reverse that opioid with naloxone. Second most common drug class that’s used are benzodiazepines, things like Midazolam or things like valium, and we have a reversal for those. A lot of clinics don’t even carry the reversal, but I would say if you’re utilizing things like medazolam or Valium in your clinic, you need to carry the reversal just in case things get crazy. And the reversal for those is a drug called flumazenil. It’s a little more expensive than naloxone.
And again, a lot of people don’t keep it regularly on their shelves. But I would say that if you have an emergency, you want to have at least one bottle of flumazenil or at least one in your, or if you have an anesthetic emergency, the next reversal agent that is very important would be antisedan or anapamazol. So this is going to reverse your dexmedetomidine or if you’re in a practice that is still using xylazine, you would want your reversal to be yohimbine, although you could use anapamazol as well working on those receptors. So you want to have antisedan for your dexmedetomidine, right? So if we came into a urgent situation, we want to make sure we have access to atropine and epi and the reversals for all of our drugs. Now, if you’re utilizing ketamine in your protocol, you don’t have a reversal agent for ketamine.
So just realize that if things get crazy and you start reversing everything, that Ketamine is still going to be on board. We don’t necessarily have a reversal for that. Now, this is just for an emergency. I will say that there are a couple other drugs that I do think of as always having in my crash cart, one maybe for some anti-arrhythmogenic effects, and then one for if we start to see maybe some irritation or something like that under anesthesia. And one of these is lidocaine and the other one is diphenhydramine. I like to keep these on board because especially with our patients that are not hemodynamically stable certain breeds, if we see a ventricular tachycardia under anesthesia, so again, this is a ventricular tachycardia, and when I say that, I mean a beat that is greater than 160 beats per minute. So if we see something like this, again, that is going to be not great for forward movement of blood and cardiac output, which delivers oxygen.
So we always want to make sure we have lidocaine available as well. Especially in these more critical patients, you might need to give like a two meg per kg lidocaine bolus if you see that your patient is in vtac. Now again, the reason I mentioned the rate is because sometimes I’ve gone into clinics where they’ll see what they describe as a slow vtac or a ventricular escape beat, or they’ll see it, but maybe the rate is still only around a hundred beats per minute or 110 beats per minute. We don’t treat those with lidocaine. That could actually make it worse. So lidocaine is for those ventricular tachycardic emergencies. And then diaphenhydramine, I usually like to have it on board because sometimes my surgeons will note, Hey, I see that this patient has had a reaction to either maybe they have severe clipper burn or they’ve had a reaction to the chlorhexer iodine that’s been used to scrub their skin and now they have hives.
So if we see something like that, we want to make sure that we can administer some diaphenhydramine to them. Okay, that makes sense. Those are some emergency drugs. And so what I like to have in my anesthesia crash cart, now, these are kind of adjunct drugs that I’ll talk about really quickly, and this is more blood pressure drugs because we know that inhaling anesthesia along with a lot of the drugs that we are going to administer like ace premises, like propofol, like afaxolone, these drugs are going to cause a decrease in cardiac output and vasodilation, which is going to lower our blood pressure. We know that hypotension is going to happen, we want to be ready for it. Now, most of the time you have a normal healthy hemodynamically stable animal. Something like lowering your vaporizer setting or administering a fluid bolus. A five ml/kg is going to get you where you need to go for some animals.
But for other animals, especially if you have a longer procedure in mind, we want to make sure that we’re not just letting that blood pressure and that mean arterial pressure dip consistently below 60 because then we know that oxygen delivery to really important tissues, it’s going to be compromised. And that’s why I always like to have some blood pressure drugs ready and available. Now, I’m not saying that every clinic has to have all of these blood pressure drugs, but the three that I keep on me at all times are going to be dopamine, dobutamine, and ephedrine. And dopamine is a mixed alpha and beta, and that’s why I really like it. If you have a patient that just a cat that’s under anesthesia for, and we know that we’re going to do 12 extractions, it’s going to be a long procedure, but their blood pressure is already not doing so great and they are also a elevated kidney value patient and I want to make sure that they don’t get too hypotensive, then I’m going to start dopamine on this patient again, we’re going to have alpha effects and we’re going to have beta effects, which means the beta is going to help to increase the heart rate and the contractility and the alpha is going to give you a little bit of a squeeze on those vessels similar to another alpha active drug dexmedetomidine.
Now dobutamine, and the reason I like to have dobutamine around is because for some animals like your mitral valve disease patients like your chronic heart failure patients, these little shih tzus that come in and they have heart disease, these guys, if we’re about to do a lung procedure on them and they get hypotensive, they’re going to do better with dobutamine. And that’s because dobutamine primarily acts at disease, can’t handle the vasoconstriction that comes along with alpha activation and dopamine. So we will go with dobutamine for these guys because it’s like it’s having a party at the beta receptor. It’s like all beta all the time. And that’s why I want to have dobutamine for those specific heart cases. And then I also like to have a ephedrine, and ephedrine is one of those because it is very, very versatile. You can give ephedrine as a one-off and it’ll last for about 30 minutes.
So I find a phedrine very helpful. It’s an alpha and beta, very similar to dopamine, but unlike having to set up a concentrate infusion like you do with dopamine, you can give a one-off of ephedrine. Now you have to dilute it out. So make sure if you’re getting a vial of ephedrine, you are diluting this out. So you have maybe a one meg per mil concentration, but then you could give a dose of it. And sometimes if I say to my clinician, well, I’ve already tried the vaporizer, I’ve maybe tried giving, I don’t think the heart rate is an issue, and you’re telling me we still have 30 to 40 minutes left of this dentistry, but I need to do something about the blood pressure. If I don’t have access to dopamine or I don’t want to take the time to set up a CRIsad, I can maybe just do a one-off of ephedrine.
And that’s really effective because again, ephedrine like dopamine effective at the alpha and beta receptors, and we get about 30 minutes of activity. So that’s what I keep in my back pocket if I just need a quick something that I don’t want to set up or I don’t have access to set up a syringe pump and an infusion and et cetera. And then some other things, just like equipment that I like to keep with me at all times is an extra endotracheal tube, an extra laryngoscope. And if you are at a practice that has access to it, certainly paddles for fibrillation. Now again, remember if we are going to use paddles, this has to be a rhythm that’s a shockable rhythm. So we’re not going to shock vtac, but if you see it’s really critical things go south and crazy and your patient is in v fib, then we can shock that rhythm.
But I will also tell you that I’ve worked in plenty of places that don’t have access to paddles and they’ve done okay with that. But this is just equipment. And the reason I’ll go back to the laryngoscope in the tube really quick is on the off chance your patient during movement from induction into the theater gets extubated during the off chance that moving the patient around on the table, they get accidentally extubated. I want to make sure that I can quickly re-intubate that patient. And again, a laryngoscope is going to be the best way to do that because it’s going to give me visualization of where I’m going with the tube. If there are any problems, et cetera, I want to be ready for those problems. And that becomes especially, especially especially important if you’re dealing with brachycephalic patients, you always have an extra tube and laryngoscope ready to go.

Dr. Andy Roark:
Yeah, that totally makes sense. This is amazing. I did not have this as clearly broken down for me in vet school as you just did. This would’ve been so helpful 15, 20 years ago. This is amazing.
Hey guys, I just want to jump in here real quick and let you know about an awesome free one hour of RACE ce webinar that I’ve got coming at you real, real soon on December the 13th at 1 p.m Eastern Time. I am working with my buddy, Dr. Simon Platt, who’s a neurologist and a really interesting person. I just had him on the podcast. If you didn’t hear his episode on Spectrum of Care neurology, check it out. It’s a great episode. It’ll give you some idea of what we’re going to be talking about. But man, he is super fun and fascinating, interesting, and I cannot wait to get in and host this webinar for him.
Anyway, it’s called Head Cases, A Spectrum of Care Approach to neurology in general practice. It is made possible generously by Nationwide. There’s no fee to you. It does have RACE CE is going to be a great presentation about neurology in general practice and keeping neurology accessible to people in times when maybe people don’t have as much money as they would like or they don’t have the ability to just throw down and do the most aggressive treatment options possible. So anyway, it’s going to be fantastic. I would love to see you there. I’ll put a link to register in show notes. Let’s get back into this episode.
Alright, wonderful. Talk to me about some dosages. So are there dosage calculators that you really like because there you are and you’re doing the procedure and this is a stressful time and things start to go off the rails. What do you do to keep those things top of mind for you in a useful way where you say, okay, this is what we need. It’s not just epinephrine to effect, but although that works, but how do you track that information? How do you keep that in a very handy format? Or do you just know it, you’re just like, I know you know it, but is that the best way to approach this?

Tasha McNerney:
It’s probably not the best way to approach it because again, unless you’re really dead on the inside and you can block everything out and just go to your rolodex of drug dosages, nevermind the things beeping and people yelling again, I can do it, but I think that’s just because I don’t know, my brain functions a little bit differently, but

Dr. Andy Roark:
I’ve had people say, how much? And I show ’em with my fingers like this much, and they’re like, that’s not science.

Tasha McNerney:
Nope. Yeah, don’t do that you guys at home. But certainly I would say for anybody who’s interested, look at the vex website. They have a lot of really great things. Look at the RECOVER initiative that’s going to give you a really nice dosing chart. And I do know that if you go to RECOVER and look at the RECOVER initiative and their website, they also have posters that a lot of clinics will use that give you the dosages of based on weight. They have a quick wait chart. So a lot of ERs and emergencies will have this just hanging in their practice where they have a really nice weight chart that’s busted down between atropine, epinephrine reversal drugs, things like, again, if you’re in an ER setting and things get really crazy, you want to bust out the vasopressin, things like that. So I really would recommend recover because that’s probably the most up-to-date guidelines as far as what the research is saying, new updated dosages and having it easy and accessible.
Another thing that I do recommend that every practice does is take those dosages and make an excel spreadsheet or an emergency drug calculator, print that out based on the patient’s current weight and have that ready to go. The time to print it out and put it into the excel spreadsheet is not when everybody’s screaming and the dog’s losing a lot of blood. We want to make sure that we do that beforehand. And again, because it’s a really stressful time, it’s nice to have this printed out and checked beforehand because again, when things are really crazy and you’re really stressed out and your clinician says to you, okay, I need you to give a certain mg/kg dose, and then your brain is like, wait, how much does this patient weigh? What’s the concentration? And you’re trying to do this quick math doesn’t usually work out well. Those precious seconds that you’re taking to calculate out this drug can make a huge difference.

Dr. Andy Roark:
Yeah, yeah, that’s fantastic. I’ll put a link to the RECOVER initiative drug doses in show notes, so people could check that out. I don’t think I need a link to Microsoft excel, but um

Tasha McNerney:
I usually say because people can make their own excel, again based on what they have in their clinic, because I don’t think that every clinic maybe has vasopressin ready to go for their patients.

Dr. Andy Roark:
Yeah, no, no, I love that. I think that makes a ton, a ton of sense. What are the most common pitfalls that you see? What are the things that people either putting together a crash cart or using what’s on their crash cart?

Tasha McNerney:
I think that most common pitfalls, at least from an anesthetic perspective that I see, is that there’s not a regular checking of the crash cart and whether or not the drugs are expired or whether or not we have enough volume of the drug ready to go. So for instance, I would give you, yeah, to actually do what we need to do. Yes, I may have a bottle of atropine in there, but if there’s only 0.4 mls, that might not get me where I need to go. So having somebody check that before the procedure, and I’m a huge fan of checklists, and you guys know me. I love checklists. I love anesthesia checklists. If you haven’t read the Checklist Manifesto, please do yourself a favor and read this. It’ll change the way you practice. But certainly having checklists in anesthesia and having somebody to go in before the anesthetic event even happens, check that anesthesia machine, check that cart, make sure the lidocaine is in date. Make sure that you have a bottle of glycopyrrolate ready and available. Make sure that if you’re going to use dopamine, again, you have enough volume to make up your cri because I’ll just give you an example. I was helping out anesthesia on a 62 kg

Dr. Andy Roark:
Wow.

Tasha McNerney:
Great. Dane. Yeah,

Dr. Andy Roark:
That’s 140 pound

Tasha McNerney:
Great Dane in for a CT procedure. And I went to look at the crash cart and our anesthesia machine in Ct and I looking at it, and I was like, yeah, we only have 1 ml of atropine in this bottle. So yeah, I have atropine and it’s in days, but again

Dr. Andy Roark:
That’s not going to make one side of his mouth dry.

Tasha McNerney:
Something goes crazy with this patient. Now I have to run to a whole other side of the hospital to get more atropine because that one ML is not going to be enough for that dane.

Dr. Andy Roark:
Yeah. Yeah, that totally makes sense. Awesome. Tasha McNerney, thank you so much for being here. Where can people find you online? Where can they learn more about anesthesia nerds?

Tasha McNerney:
Yeah, so the Veterinarian Season Nerds is currently a Facebook group, and that’s where we do a lot of our discussion and case-based stuff. But you can also find us on the website. And on the website we have links to the Veterinary Anesthesia Nerds podcast as well as a calendar of events. So you can see where all of us are speaking. And when I say all of us, I don’t just run anesthesia nerds by myself. I am joined by Darcy Palmer, who’s a VTS in anesthesia, and she works out in Alabama. And then I’m also joined by Steven Sital, who is a VTS in, again, not only a VTS in lab animal, but also a surgical research anesthetist and just a wealth of information there. So we have a calendar, so you can see if you wanted to come hear us talk or lecture, we have a calendar on there as well. And then we have a contact form as well. So if you have something that you wanted to ask the anesthesia nerds or you wanted to request some help for something, you can get us there.

Dr. Andy Roark:
That sounds fantastic. Awesome. Thank you so much for being here, guys. Thanks for tuning in. Take care of yourselves. Have a wonderful rest of your week.

Tasha McNerney:
Thanks for having me.

Dr. Andy Roark:
And that’s it. That’s the episode, guys. I hope you enjoyed it. I hope you got something out of it. I said, you can see now why this is the Hall of Fame episode for us, and why so, so many people loved it when it first dropped. Guys, take care of yourselves, everybody. I’ll talk to you later on.

Filed Under: Podcast Tagged With: Medicine, Vet Tech Life

A Spectrum of Care Approach to Neurology

December 4, 2023 by Andy Roark DVM MS

Dr. Simon Platt and Dr. Andy Roark dive into neurology’s challenges, emphasizing individualized care and accessible diagnostics. Dr. Platt introduces a forthcoming neurology resource aimed at providing comprehensive information for neurology enthusiasts, all in the pursuit of demystifying neurology and prioritizing accessible patient care.

Cone Of Shame Veterinary Podcast · COS – 241 – A Spectrum Of Care Approach To Neurology

This episode is brought to you by Nationwide Pet Insurance.

LINKS

Spectrum of Care

Nationwide’s Pet HealthZone

Web-Vet Neurology

Dr. Simon Platt on LinkedIn

Upcoming Webinar with Dr. Simon Platt

Dr. Andy Roark Resources 

Dr. Andy Roark Swag

ABOUT OUR GUEST

Dr. Simon Platt, a distinguished European and American veterinary neurologist with 23 years of academic expertise, embodies a passion for teaching, research, and clinical excellence. His extensive contributions encompass over 240 published scientific papers, including 70 chapters in renowned veterinary publications. Notably, Dr. Platt has co-authored five authoritative textbooks in veterinary neurology, showcasing his commitment to advancing the field’s knowledge base.

A trailblazer in academia, Dr. Platt has secured over $3 million in grant funding, led NIH translational research teams, and held pivotal roles within committees for ECVN and ACVIM. For over two decades, he has mentored neurology residents globally, while his dedication to education extends through the management of educational websites, notably featuring a pioneering 3D virtual-reality dog model for practical neurological examination teaching. Additionally, as the founder of SEVEN, a not-for-profit group, he established an annual southeastern regional clinical neurology conference, fostering collaboration and knowledge exchange within the field.


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 great one for you today I am here with Dr. Simon Platt. He’s a veterinary neurologist. I did not know him before we sat down to record. This is my first time meeting him. His resume is amazing and so I just start off with that. But he has done so much and he is so smart and man is he approachable and easy to talk to and I could listen to him talk for hours and hours. So anyway, I was thrilled to get to talk to him. He has this really interesting way of looking at neurology, this genuine desire to bring it to general practice and to make it not intimidating to GP’s and just to help keep care affordable and accessible for people. And you’re like neurology and affordable don’t tend to go together.

You got to hear what he has to say. It’s just been really good. It is a great conversation. Anyway, I’m actually doing a webinar. I am hosting Dr. Platt for a webinar December 13th. It is made possible by Nationwide. It is totally free for you guys. I’ll put a link in the show notes to register. It’s got RACE CE attached to it. It is a sweet deal. I am really looking forward to it. After our conversation today, I’ve got pages of notes. I’ve got a bunch of questions from our conversation that I’m sitting on until we get together. So anyway, that’s coming up. This is a great episode. I have talked long enough. Guys, this episode is made possible ad-free by Nationwide. Let’s get into it.

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

Dr. Andy Roark:
Welcome to the podcast Dr. Simon Platt. Thank you for being here.

Dr. Simon Platt:
Thank you very much. It’s an honor and thanks for the invitation.

Dr. Andy Roark:
Well, it is a huge honor to have you here. For those who do not know you, you are a board certified European and American veterinary neurologist. You have published over 240 scientific papers. You have co-authored five veterinary neurology based textbooks. You have gotten a bajillion dollars in different research grants. You have have trained neurology residents for 22 years. This podcast is beneath you, sir. That’s what I think.

Dr. Simon Platt:
No, I’m still the poster child for imposter syndrome and after listening to all of that, I wondered it “Was that me? Where have those years gone?”

Dr. Andy Roark:
It’s a blink of an eye. But anyway, it is an amazing resume. I am happy to have you here for a number of reasons. The first one is I am going to be hosting you in a webinar. You and I are doing a webinar together on spectrum of care neurology cases on December the 13th. It’s made possible by Nationwide, which is very lovely of them. So it’s free for everybody, but I’ll be hosting you. It’s a one hour webinar. It’s got an hour of RACE CE on it. I’ll put a link in the show notes. It’s for people to register for that, but you and I are going to get to talk then. And before we did that, I always like to talk to people in sort of a more conversational format. And so I thought this would be a good opportunity for us to start to talk about something that I’m really interested in and that’s accessibility and it’s spectrum of care.

So what I mean when I say that to lay out some terms, I have concerns about keeping veterinary medicine available and affordable for pet owners. And so one of the things that is really interesting to me is looking at people like yourself who have such deep expertise in specialties and saying, what does this look like at the general practice level to do right by the patients? And it’s always that balance of advocating for patient care and for doing what’s right for the pets and educating the pet owners and also trying to meet pet owners where they are. And neurology is a particularly intimidating specialty to me when I look at it from this standpoint because it feels like very quickly we get to the multi-thousand dollar MRI machine. And I also have felt, I’ve had the feeling as a general practice doctor before looking at neuro cases of like, I can’t cut this, I can’t cut this. My medications feel fairly limited. It can feel like there’s not a lot of options when I’m looking at a neurology case. And so anyway, let me just pause there and open that up to you. What is your general philosophy when you look at neurology in an access to care capacity?

Dr. Simon Platt:
Yeah, I mean you touched on a lot there. I would have to admit neurology is very intimidating. That’s the first problem, not just to us as veterinarians. I mean, I remember starting out and to me I really hated neurology. We got taught by a stand-in neurologist who was our cardiologist. She admitted she hated it. She said, I’m not really sure what I’m doing here. I’ll teach you some neuroanatomy and then we’re away. And it didn’t really make sense. I thought, well, everything I see seems to circle, get steroids and die. This doesn’t really make sense. And so I was a bit scared of it. Now it’s intimidating on every level. The clinical exam is intimidating. Look at some of the other specialties and some of those are intimidating, but the clinical exam part, that’s not dermatology to me, very intimidating. But the clinical exam doesn’t seem that intimidating.

But for neurology, very intimidating check sheet based, you check these things, you don’t really know what does that mean, but I’ll just check it. No one’s watching and it doesn’t really add up. And so we need to get rid of that. That’s the first thing. But then it goes on because as you said, it seems like you can’t do neurology without expensive tests, invasive tests, and it seems that you can’t do neurology without surgery. And so I’ve approached it from the general practice background that I had where I was frightened of it, intimidated of it, trying to work out how on earth I could actually do it without some of those tests where we came from a background where MRI wasn’t actually being used. And so the spectrum of care approach was something that I kind of adopted early but didn’t really know how to articulate it, didn’t really know to say, well, this is spectrum of care.

To me it was all about individualized medicine, individualized for the client and for the pet. So for the client, you are individualizing it based on their personal circumstances, obviously finances, their geographic location, could they get places to do further tests? What’s going on in their life? Are they working 16 hours a day? So we’re making some decisions around that. And then we’re making some individual decisions around the patient as well. Because a patient that’s two years old that has condition A would be treated very differently from a patient who’s 19 years old that has condition A maybe has exactly the same signs. And so we’ve got to take those into consideration and that’s what all of us, I think, in this profession do. And so all of a sudden then it had a name of the spectrum of care. And I felt that’s helped because I feel right at the start we talked about poster children, but poster children.

I think for spectrum of care, one of them is neurology because we have to be able to offer a stepwise approach in diagnostics and a stepwise approach in therapeutics. And the problem that we have many times is that other specialties, other areas of veterinary medicine can do this based on a lot of evidence in terms of what the disease is. And we never get there because without a biopsy of the brain or of the spinal cord, we never have a precise answer. Whereas obviously if you’re dealing with liver disease, you may have a biopsy, you’re going to have other areas of veterinary medicine where it’s a little easier, a little cheaper, a little safer to get a diagnosis. For us, we’re always even spending thousands of dollars MRI type, you’re always guessing. And so I’ve encouraged our students to stand up and have a mantra and say, I’m a veterinarian. I love to guess. And that’s not playing down evidence-based medicine, because you need the evidence to piece together the facts that are given to you. Let me see this dog with this signal and these presenting signs and this neurologic exam piece, those pieces of the evidence together and come up with, well, what could it be and how would they respond to the treatment? So the evidence is out there for those aspects of the case, but not really of what exactly does it have.

Dr. Andy Roark:
So lemme jump in here because a couple of things that struck me. First of all the, for a moment I thought if I ever wrote about a book about neurology, I would call it circle get steroids and die. But now I think I would change that. I think I’m a veterinarian. I love to guess is a better title for the neurology book that I would write.

Dr. Simon Platt:
And the follow-up would be, I am a neurologist, I love steroids. And now some people will be tuning out and going, can’t believe he said that, but I know when the lights get turned out. That’s what the dogs and cats, that’s what we’re using. It’s just about appropriate use. So circling steroids and maybe doesn’t do so well, you need to know the dose of steroids. That’s the evidence in there.

Dr. Andy Roark:
I love it. I always love specialist secrets where they’re, I will tell you I have a hundred percent referred patients to a specialist because, and I knew they were going to give steroids, but I didn’t have the guts to do it. And so I gave it to them and they took the liability and they did it. So it sounds to me like what you’re saying. I just want to clarify that. So first of all, I love the fact that you come from a place in the general practice background and this was intimidating and neurology was scary. I can resonate with that. And I think a lot of other people, it sounds to me like what you’re saying is because getting an actual indisputable diagnosis is so hard, that makes it much more challenging to break neurology down into sort of a clear diagnostic step to a clear diagnostic path that we could walk through because we don’t end up with enough evidence because we don’t often get all the way the diagnosis. And so the fact that we don’t come with that diagnosis makes it harder to teach doctors. This is step one, this is step two, trust your instincts. This is step three. Is that sort of what you’re getting at there?

Dr. Simon Platt:
Yes. But there has to be still somehow a step one, step two step here. And I think therefore with neurology it’s going to be different. What we will use is the evidence behind the presenting signs, for instance. So our presenting signs could be sudden onset or slow. They could be accompanied by pain or not. They could be progressive or static. And so we’ll look at neurology as a series of presenting signs that will help us try to narrow down what the problem is. And so one of those other presenting signs will be, is it asymmetric or not? And so for us, if we’ve got asymmetry, however we see that either just on observation or on taking it further with a hands-on exam, that’s a factor we’ll throw into speed of onset progression of disease, presence of pain or not, because those things will help us narrow down our differential diagnosis list.

I dunno about you, but originally I was taught to think about neurologic diseases using that pneumonic damn knit V and I didn’t know I remember that what that was. So we shuffle the letters around and we’ve come up with vitamin D and I used to teach at Georgia and no one knew what that was. And so I shuffled that around and said vitamin D, and then everyone got it. And what we’re talking about here is the letters, right? Those letters of that acronym there, those letters V for vascular will go down all of those mechanisms of disease and look at, well, what would you present? So if you are vascular that’s in the brain, that would be a stroke. You are sudden onset, you are asymmetric, you are non-progressive. And so now I look at the dog and say, could you be that next thing eye for inflammatory?

You are subacute to chronic, you are progressive, you are often patchy, multifocal, you’re asymmetric. Could you be that? So our step-by-step approaches is let’s answer some questions. Question one is are you really neurologic? Right? That seems like an odd question because many of the times we know straight away they’re dragging their legs or they’ve got a head tilt, but sometimes we’re obviously presented with a case that can’t jump into the car anymore or go up the steps. And so is that orthopedic or neurologic? So step one, are you neurologic? Step two, where’s your disease? And I don’t want then people to become intimidated further by neurology and say, oh no, this is where neuroanatomy comes in because really we’re looking for is your disease in the head or out of the head? That’s where the separation of disease types occur. So our next question then, where’s the disease in the head out of the head?

And then the third question is using this clinical reasoning approach where we try to look at how you are presenting asymmetric, progressive and sudden onset. For instance, we’re going to look at those differentials, V for vascular, I for inflammatory, T for trauma and toxin A for anomalous. We go down the list. And so our step three is what could you be? And at that stage we can communicate with the owner and say, here’s two, maybe three possibilities. And of those we could maybe narrow those down with some further tests and we’ll show you how we’ll do that. So we might not need to advance all the way to the most expensive and invasive tests. And if the owner says “We haven’t got any money for any of those tests,” then we look at those two or three possibilities with an eye for treat for the treatable, and again, stepwise go with the least invasive, maybe the cheapest, maybe the most effective potentially medication. If that doesn’t work, we’ve got a plan for step two and three. So yeah, diagnosis and treatment will still have that stepwise approach without really knowing what they’ve got.

Dr. Andy Roark:
Do you find that walking through this process and you get down to, is it in the head? Is it out of the head? And then sort of going to the owner and saying, all right, here’s a bucket. And I guess that’s kind of how I think of it is I can’t tell you what it is, but I can kind of tell you what bucket it’s in. That allows me to start to have some realistic conversations about what treatment wouldn’t involve or what further diagnostics would involve. We can start talking about prices of things and what options are going to be available to them. I don’t have to know what the answer is, but I have to tell them where I think this path ultimately probably goes or what that journey looks like. And then we can start to talk about where they are, what their resources are, what their intentions are, what their feelings are. Is that kind of how you of look at this and how this sort of shakes out into helping guide people and give them insight when you don’t have a diagnosis?

Dr. Simon Platt:
Yeah, we’ll have those two or three possibilities or buckets where we can say if you have disease, a bucket one, let’s say it’s possible stroke. If we do nothing, this is what happens if we treat, what are we treating with? What’s the advantage and disadvantage of doing tests? For instance, if it’s a stroke, there is no specific treatment. And although with tests such as MRI, you can gain more confidence, there’s nothing definitive and they’ll get better many times in the next two or three days. And so we’ll offer owners, well that path takes you down, do nothing for two or three days. If they get better, you’ve got your answer. And then bucket B, this case will get worse if we do nothing. So again, then we’ve got some help there by just using time on our side as a diagnostic, and this is what you’ll get with bucket B.

Let’s say it’s inflammatory. If we do just blood tests, this is what we’ll get. If we do an MRI, this is what we’ll get If we do C, S, F, this is what it’ll cost, pros and cons of each of those things. And again, we can often help the owners feel comfortable with not going to the extent of doing all of those tests by saying this is the difference it will make if we do the tests. Because ultimately this whole thing about I’m a veterinarian, I’m a neurologist, I’d like to guess MRI sounds like it should give you the answer, but it doesn’t. It’s not often definitive, it just improves your confidence level. And so many times we’re still looking at it and saying, I don’t really know. Is that a tumor? Is that inflammation? And so then we’re still guessing and we’re still then going to treat for the treatable. So I know in a may say, well, what was the advantage of even doing that? And that’s a killer comment because that means we haven’t communicated upfront that you might actually get no benefit of doing these tests.

Dr. Andy Roark:
Do you have or have you had any sort of apprehension about sort of trying empiric therapy when you don’t have those types of diagnostics? When I look at the sort of medications we reach for in our neuro cases, I think I always worry, what if I’m wrong? What if I put this dog on an anti-seizure medication and that’s not the right play? Or what if I reach for steroids and this is not the right play? I don’t tend to have nearly that much apprehension in internal medicine cases or dermatology cases and I don’t necessarily know why, but it’s something scary about, I don’t know, maybe it’s just those, my experiences with those medicines, they still kind of feel like voodoo to me in some ways. Maybe that non-steroidals don’t feel like voodoo to me or antibiotics don’t feel like voodoo. Does that make any sense at all?

Dr. Simon Platt:
Absolutely. Because I think in the past we’ve been taught to be scared of neurology because if you don’t know all of your neuroanatomy inside out, then you can’t do neurology. Not true. If you don’t have an MRI, you can’t do neurology. Not true. And therefore you feel, well if I don’t really know what the disease is, how can I come up with treatment and the brain and the spinal cord, they shouldn’t be messed with. If I get this wrong, they die. Well, I think that’s the same with multiple diseases. I’d be scared of treating a dog with cystitis. So I mean it depends where you come from. So for me, I have no problem with empiric therapy as long as I’ve had a completely transparent discussion with the owner to say this is what I think’s going on. Two possibilities, three possibilities. This is the best thing for the dog right now.

If we are aiming to see if we can get some improvement, how far will it go? Maybe we don’t know what happens if it doesn’t work. We need a plan B. What’s the worst that could happen if it doesn’t work? And then the owner has a chance to come back and say, well, I don’t like the worst option. What would I do to avoid that? And we can discuss whether tests at that stage are going to help or not. And sometimes they say, well that’s great that you say now an MRI will help but I still don’t have any money. Well, so we’ll address the discomfort that comes from the fact that empiric therapy is an unknown by saying, well if we do nothing, I’ve got more of a known for you. And that is there’s going to be progression potentially or there’s going to be pain. So the empiric will focus on quality of life and so making sure they’re comfortable above all else. But then also looking at, well if you have something that’s treatable, what could it be? If I’m looking at inflammation in the brain versus the tumor in the brain, I’m going to go with treating inflammation because that’s likely to have a more positive effect than anything I can do for the tumor regardless of how much money that you have. And there’ll be some collateral benefit for the tumor if I use anti-inflammatory steroids.

Dr. Andy Roark:
Yeah. Simon, before I let you go, I want to jump back and do the vitamin D with you. And so just to run through it, it’s funny, the acronym is one that I heard back in vet school and it’s been so long and you bring it back up and we start to go through it. So just for our listeners to have it, vitamin D, we’re talking about the origin of a neurologic problem. V is vascular, I is inflammatory, T is trauma or Toxin A is anomalous.

Dr. Simon Platt:
Yeah. So anomalous being, yeah, you’ve been born with something. So in the brain that’s hydrocephalus in the spine. Then if you’re a frenchie, that’s a vertebral malformation. And then we’ve got M for metabolic. So that most of the time is a brain problem rather than a spine problem. Hepatic encephalopathy is a good example. And then we move to I for idiopathic, and that again is on the top 15 list of why people hate neurology because idiopathic, well isn’t that when I find nothing? So isn’t that everything? And so we have to get across that. Yes, you’re right. But idiopathic is for specific conditions. They’re loner conditions where there’s nothing else. So epilepsy, facial paralysis, vestibular, so they’re loner conditions, you’ll find nothing else. And then we’re down to N for neoplasia. And again, we’ll use all of our factors like the average age for brain and spinal neoplasia is eight, so we’re going to throw that in.

If you’ve got a two year old patient, then neoplasia is dropping lower on your list. And then N also is for nutritional, which for a while in my career fell off the map and now is right back on it because people think you should feed raw meat and bones. And so now we’re seeing a lot of nutritional problems hit the brain. And then lastly, D is degenerative in the spine. That is disc disease and myelopathy. And then in the brain really we’re dealing with old age degeneration, a little like Alzheimer’s, a cognitive dysfunction. So we use that list, that sort of acronym there to help us remember what exists in the brain and the spinal cord and we can just cross those off based on how you’ve presented. And so of that list based on your age, based on was it sudden or not based on is it asymmetric based on is if there’s pain, I could cross them off and say, I’ve got one thing left for you, two possibilities.


And maybe one of those isn’t treatable. And now we’ll talk about tests as to whether they will really help or not. And sometimes we won’t perform tests. If I have a seizure inpatient, for instance, 50% of them meridia pathic, and my evidence-based medicine is going to tell me that if you’re idiopathic, you’re pure bred, your age is between six months and six years, you have no neuro deficits. So if I see a two-year-old golden retriever with no neuro deficits having had a seizure, I’m probably not going to be advising MRI tell people, spend your money on the medication. If we need to start treating, if things start coming out of the woodwork in the next few weeks and things change, that may be the time to talk about being more aggressive.

Dr. Andy Roark:
I have about seven follow-up questions and I’m, I’m going to sit on them, I’m going to sit on them until your lecture in December. I could talk to you all day. I really appreciate you being here. Where can people learn more? Do you have favorite resources? And then where can people find you online?

Dr. Simon Platt:
Well, I’m on LinkedIn and so you could find me there. We’ve just actually opened, if that’s what they say, I’m sure it’s not a new website published. Is it? We’ve just released

Dr. Andy Roark:
Launched?

Dr. Simon Platt:
Launched. That’s best.

Dr. Andy Roark:
Unveiled?

Dr. Simon Platt:
What do people say that? launched is good? Yeah, we’ll go website, which is under construction, but you can start to get a feel of it. It’s for neurology for all ages, so to speak. And it’s called web-vetneurology.com. And so we’re going to expand that into hopefully extremely useful resource. We’ve got cases on there, we’ve got some literature on there right now. It’s not as useful as it’s going to be because we’ve got a lot of nuts and bolts, grassroots, grassroots information to add to it.

Dr. Andy Roark:
Perfect. That sounds fantastic. I’ll put links in the show note to all of that. Guys, thanks for tuning in and listening today. Simon, thank you for being here, gang, take care of yourselves, everybody.

And that’s it guys. That’s our episode. I hope you enjoyed it. I hope you got a lot out of it, man. I genuinely, I love this episode. Thanks to Simon for being here. Thanks for talking. I am looking to our, looking forward to our webinar together in December when we’ll be breaking this down in more detail and probably uses the visual aids and some slides and some things like that. So anyway, I would love to see you there. I’ll put a link in the show notes if you want to come to that free webinar, get some RACE CE, hang out with me and Simon. It’ll be a good time anyway, take care of yourselves, everybody. Have a good day. I’ll talk to you later.

Filed Under: Podcast Tagged With: Life With Clients, Medicine

Veterinary Cardiology Myths, Legends and Fears

November 27, 2023 by Andy Roark DVM MS

Veterinary cardiologist extraordinaire Dr. Kristin MacDonald teams up with Dr. Andy Roark to debunk the myths and unravel the legends swirling around cardiology. From heart attacks in dogs to the controversies surrounding grain-free diets, they dissect it all. Tune in as they sift through the maze of modern ideas floating on the internet, separating fact from fiction, and shedding light on what holds true in the world of pet heart health.

Cone Of Shame Veterinary Podcast · COS – 239 – Veterinary Cardiology Myths, Legends And Fears

This episode is brought to you by CEVA Animal Health!

Important Safety Information: Do not administer in conjunction with non-steroidal anti-inflammatory drugs (NSAIDs) in dogs with renal insufficiency. Do not use in dogs with hypoadrenocorticism (Addison’s disease), hyperkalemia or hyponatremia. Do not use in dogs with known hypersensitivity to ACE inhibitors or spironolactone. The safety and effectiveness of concurrent therapy of Cardalis™ with pimobendan has not been evaluated. The safety of Cardalis™ has not been evaluated in pregnant, lactating, breeding, or growing dogs. Cardalis™ administration should begin after pulmonary edema is stabilized. Regular monitoring of renal function and serum potassium levels is recommended. Common side effects from a field study include anorexia, vomiting, lethargy, diarrhea and renal insufficiency.

LINKS

Cardalis Resources and App

CEVA Connect

Upcoming Webinar (Free RACE CE)

Dr. Andy Roark Resources 

Dr. Andy Roark Exam Room Communication Tool Box Team Training Course

Dr. Andy Roark Charming the Angry Client Team Training Course

Dr. Andy Roark Swag

ABOUT OUR GUEST

Dr. Kristin MacDonald earned her doctorate of veterinary medicine in 1998 from Auburn University, and then completed an internship in small animal medicine and surgery at Michigan State University in 1999. She finished a residency in veterinary cardiology at University of California, Davis in 2001 and became a board certified veterinary cardiologist in the American College of Veterinary Internal Medicine in 2002.  She continued her education by earning a PhD at UC Davis Comparative Pathology graduate group in September 2005 on hypertrophic cardiomyopathy in Maine Coon cats, and the effects of ACE inhibitors.  Dr. MacDonald taught on faculty at UC Davis for a year, and then became the clinical cardiologist at the VCA Animal Care Center of Sonoma County in Rohnert Park, CA, where she continues to have a busy cardiology practice. She has been an active author of book chapters for highly respected textbooks, served as section editor for Handbook of Small Animal Practice, published a multitude of original research papers, and is coauthor of The Textbook of Feline Cardiology, the only text of its kind available.  Dr. MacDonald has participated in clinical trials involving treatment of canine congestive heart failure, and enjoys being the lecturer for the VCA Cardiology Series in the United States. Living in Sonoma County, she enjoys spending time outdoors hiking, skiing, and being mom of two daughters, two Tonkinese cats and a Labrador Retriever.


EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame veterinary podcast. I am your host, Dr. Andy Roark. Guys, I am here with veterinary cardiologist, Dr. Kristin MacDonald. Today we are talking about cardiology myths. We are walking through a little bit about heart murmurs, a lot about heart failure, a lot about communicating the heart failure to clients, a lot about managing heart failure. We talk a bit about Spironolactone and why it has become so popular in cardiology and it’s all sort of presented in the format of myths and legends that I have heard and mostly I’ve seen online with pet owner groups, things like that, pet owner discussions, and I’m just putting that out to her and seeing how she communicates about these things and really what the truth is. So anyway, this is a super fun episode. It is a great bite-sized chunk episode. We just clip from one subject to the next subject to the next subject. It’ll definitely hold your attention. You’re definitely going to pick up some pearls along the way. Kristin is amazing, was so glad to have her. Guys, this episode is brought to you by Ceva Animal Health. 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. Kristin McDonald. How are you?

Dr. Kristin MacDonald:
I’m great. How are you, Andy?

Dr. Andy Roark:
I am so great. I am so glad that you are here. I have been looking forward to getting to sit down and talk with you a bit. For those who do not know you, you are a clinical cardiologist at VCA Animal Care Center in Sonoma, California. You are a huge outdoorsman, which I love, and you live in a beautiful place for it. You are also have two daughters just like I do, and you are teaching one of them to drive just like I am. I feel like we’re living parallel lives except for the whole cardiology thing. You are also a lecturer. You are doing VCA lecture series all across the United States. People can find you all over the place in your presentations. So yeah, thank you. Thank you so much for making time to be here. I’ve got a fun game and it is, I wanted to share with you some cardiology myths. I want to make some bold statements and I want you to shoot ’em down. So yeah, I want to go ahead and lay out some things that I am starting to hear or things that have kind of floated around the internet and I just want you to weigh in on some of the modern cardiology legends. Is that okay?

Dr. Kristin MacDonald:
That sounds great.

Dr. Andy Roark:
Alright, great. So first thing I’m going to start with is talk to me a bit about pet owners that are concerned about their dog having a heart attack. And so I see a lot in people. I’ve heard people say that dogs don’t have heart attacks. They’re like, dogs have heart attacks. I’m like, well, they do. And then people talk about heart failure and they’ll use heart attack interchangeably. Like, oh, well the doctor says he’s going to have a heart attack, and I’m like, nobody did that. Talk to me a bit about heart attacks in dogs and that terminology, if you don’t mind.

Dr. Kristin MacDonald:
Well, most clients actually equate heart disease in dogs to what they might suffer in human cardiology, which is a heart attack and it really is not the same thing. So dogs have a lot of different heart diseases, some that are in common with people, but they don’t have coronary artery disease and atherosclerosis. And I’m guessing it’s because we probably feed them better than we eat ourselves. Looking at my diet lately of lots of pastries and french fries on vacation, my dog eating way better than me. So there are certain things that may look like a heart attack that they may clinging to in severe forms. Their pet might be short of breath or breathing hard or coughing or collapsing. And so those things look like a heart attack, but it’s actually a very different process to a severe process. So we try to explain the actual heart disease that we think is going on with their pets so they can better understand it.

Dr. Andy Roark:
A couple of years ago, the grain-free heart disease was everywhere. It was huge thing. It blew up. There was much conversation about grain-free diets and their interaction with heart disease and things like that. That seems to have quieted way down. We don’t hear a whole lot about grain-free diet associated dilated cardiomyopathy anymore. Is that over? Is grain-free diet, heart disease a thing of the past?

Dr. Kristin MacDonald:
It is not over. It’s just not front and center on people’s minds. And unfortunately there are still cases of this. This was first described back in 2018 when we started seeing dogs that weren’t supposed to have dilated cardiomyopathy like little dogs that never get that disease. And we were looking at common threads and sure enough it was these grain-free diets that seemed to be emerging as this common factor. So there was this frenzy of learning and reporting to the FDA, which was a very arduous process for clients. It could take 30 minutes for them to have to fill out all this information and there gets to be fatigue in the process and fatigue with investigators. So there’s still ongoing active research, but I think that maybe the word has gotten out and maybe there’s been some reformulation of different diets, but there’s also very sneaky ways that companies are sorting the term grain free. And so they may call it grain friendly, but they still may have the same potentially toxic ingredients. We’re learning that it’s the legume family like peas and so they might call it green friendly where it’s more approachable. They still kept the peas in it. So we still are finding dogs with this and they can die from it. Changing the diet and treating for heart disease in these dogs can make a dramatic improvement in their outcomes. So it’s still around.

Dr. Andy Roark:
I can’t fathom. I’ve seen grain friendly and I’m like, oh, clearly they have addressed the concerns. But you say, but not necessarily.

Dr. Kristin MacDonald:
You have to look at now. It’s harder. You can’t just look at the title of the diet. You actually have to look at the ingredients list. It’s very complicated.

Dr. Andy Roark:
Oh man, I’m going to have to sit with that. That’s amazing. Talk to me about having seizures with heart problems. So I’ve had pet owners, I’ve seen posts on the internet where pet owners are like, yeah, my dog have heart disease and now he has seizures. How do you talk to people about seizures when their dog has heart disease?

Dr. Kristin MacDonald:
This is something or

Dr. Andy Roark:
Perception of seizures. Yeah.

Dr. Kristin MacDonald:
Oh, yes. This is something. Now full disclosure, I’m married to a veterinary neurologist, so this is a sensitive subject here. And we also happen to work in the same practice. So we’re often jockeying for whose case is this?

Dr. Andy Roark:
Well, hold on to jump in. Your father is also a veterinary dermatologist. Is that true’s like Oh, Thanksgiving’s at your house? Yeah.

Dr. Kristin MacDonald:
There was one actual Ettinger textbook that the three of us all had chapters in it and the table of contents had us in sequential order.

Dr. Andy Roark:
That’s got to be a record. That has to be a record. That’s super cool. Okay, I’m sorry. I didn’t mean to interrupt.

Dr. Kristin MacDonald:
So back to every time an animal has something where it looks like they collapse, they may lose consciousness, they may have some tonic CLO movement. They almost always call it a seizure, and it’s very difficult even in the best trained eyes and education to differentiate them. I’ve actually seen a dog in the ICU with an EKG on that went into horrible vtac, collapsed and fainted, and then had myoclonic movements that looked exactly like a seizure. But I had the EKG on and he had minimal blood flow and it was syncope. So of course an untrained client would think it’s seizure, but you’ve got to think twice about that and it’s hard for the GP because they’ve got to decide completely different directions to go, is this a really malignant cardiac event, cardiac or is this neurologic? Who do I send this to or what treatment should I start?
So it can be tricky because they can have similar appearances, but there’s a few things that I’m going to look for. I’m going to look at is there an inciting cause for syncope? It might be that it’s excitable or exertion related or triggered by a cough, or maybe it’s a small breed dog with chronic respiratory clinical signs in murmurs where for seizure it may be more likely at night when they’re resting and they may have different behaviors before and after, but it can be super tricky. But generally when a client says it’s a seizure, I would urge you guys to dig in deeper, get a little more info, look at your patient signalman and decide which direction should we go. And if there’s any questions, I’d be dialing up your favorite cardiologist or neurologist and tell them about it. Ask for a video.

Dr. Andy Roark:
Yeah. Well, I love the video suggestion, and this is always interesting because it really is the clinical history and asking the questions and kind of digging in. Do you still put halter monitors on dogs that you are playing around with syncope? Is that still a standard of care that you reach

Dr. Kristin MacDonald:
For? Oh yes. So for sure the first thing we’re going to start with is in my cardiology practice is we’re going to do a really comprehensive echocardiogram. We’re going to look for pulmonary hypertension, especially in small breed dogs, really common cause of syncope we’re going to have an EKG on, but you never luck into that aha moment. That’s when we really lean on the Holter monitor where we may place it for a day or even up to seven days to try to document arrhythmia and maybe we can catch the event and actually show whether it is from an arrhythmia or not, and then that will implicate your treatment because we have many great drugs out there, anti-arrhythmic meds, or even pacemakers we’ll use in dogs to really cure the problem.

Dr. Andy Roark:
Yeah, there’s a lot of conversation when I look online and I look at pet owners that are talking about their pets with heart disease and things like that. There’s a lot of fear. So one of the questions I’ve honestly seen online is people say, my dog has a heart murmur. Does that mean he’s going to die? Again, I think I bring this up because I think all of us in vet practice, we see heart murmurs all the time and we know that, but I think sometimes we take it for granted that the pet owners, they’re going to understand when we don’t act like it’s a big deal, so they’re going to understand it’s not a big deal. But I don’t think that’s necessarily true. How do you talk to pet owners about heart disease, about their heart murmur, which can hit them like a hammer when they go, what do you mean my little dog has a heart? What do you mean her heart has a valve that’s not working the way it should? What is that conversation like with you?

Dr. Kristin MacDonald:
Well, actually you catch it first, so I feel for you very much because you’re the revealer. And then I have clients that come in and they’re on the ledge. They are holding their breath, they are wringing their hands. You can see every bit of body language is fear. The dog’s not afraid, the cat’s not afraid as much, but the client’s terrified. So I love it when I can come back into the room after we’ve done our workup literally 25 minutes later and say, one of my first things is we’re okay here. And so it’s really disgusting that a murmur doesn’t mean your dog is going to die. And in fact, the odds are greatly in your dogs or your cat’s favor that they’re going to be okay. But this can get worse over time. And if we’re talking about the number one cause of murmurs in dogs, it’s going to be mitral valve disease, which yes, this can get worse over years of life, but again, if you’re a betting person, two thirds of dogs are going to live full lives with mitral valve disease. So it’s kind of giving them a little bit of reassurance and also committing them to the fact that things can go wrong and we need to stay on top of this. And that means we need to proactively prospectively watch these dogs and really monitor them to know when do we need to get worried and when do we need to start medications because certainly heart disease is not always benign and it can really progress to become problematic.

Dr. Andy Roark:
How do you handle the pet owners who, I mean again, so we talked about heart murmurs. When we start talking about heart failure, I have had clients come up to me or people who aren’t my clients, they talk to another vet and it’s almost like they have a question they’re embarrassed to ask their vet. So they say heart failure, that means he’s going to die, right? Heart failure is you can’t live if your heart fails and he’s in heart failure, does that mean he’s dying? And so unpack that for me.

Dr. Kristin MacDonald:
I literally had that happen to me last week. I kid you not right before this podcast. I was like, oh, this is it. This is definitely a myth that we need to dispel that heart failure is concerning. It’s a scary word because oh, it’s terrifying. This is a big deal. I mean, this is not a benign process typically, but it doesn’t mean your dog is dying on the floor in front of us. It means that your dog has severe heart disease severe enough that it cannot function properly, such that fluid will build up in the lungs or in the abdomen, or maybe they have really low blood flow so that they’re really tired going on walks or they’re coughing and breathing hard in that yes, heart failure, there are medications do help it just in people and think they may relate to that. They know like, oh, I have a lot of clients that go, well, I have heart failure.
I’m on that med. And so it almost makes them a little more comfortable to know we can treat this. But yes, overall there is a accelerated time course compared to people that can live with heart failure for 10 years, 20 years in dogs. I mean, it’s sad about most dogs with mitral valve disease and heart failure may live on average a year. Then again, we have some great success stories for longer and for dilated neuropathy, it’s even shorter. So there is this, in my approach, it’s an honest, gentle preparation for them so that we’re not sugarcoating things. We’re not trying to diverge from the truth, but we’re trying to support them, trying support and let them know what might happen, what it might look like. They always want to know what’s it going to look like, what’s the end going to look like? And I think it’s really helpful to discuss what it could be like with breathing difficulty that maybe it’s a phone call, kind of things are getting worse or maybe it’s a crisis and you need to get help urgently.

Dr. Andy Roark:
Do you think that you can have those honest conversations about what heart failure looks like and then still have sort of a voice of optimism?

Dr. Kristin MacDonald:
Yeah, absolutely. I think that I try to talk about that this is treatable and kind of a plan for what this looks like, but then we do have to talk about when things don’t go right. But also the fact that even if we have a dog that represents with heart failure, it doesn’t mean that we can’t make more adjustments and get more quality time. And I also think it helps with buy-in for medications because in veterinary medicine we don’t have so much success or there’s not as much availability of valve replacement. So really the mainstay of treatment cross country is medical therapy. And so if they know this is a deadly disease and we worry most about how they feel that medications are going to help deliver that improvement as best as we can, and we need them to be compliant and follow up and know what to look for that are concerns to let us know so we can be proactive.

Dr. Andy Roark:
Okay. Well, speaking of medical therapy, one of the things that I have seen in the last 16 months I have never seen since I was in vet school and learned about spironolactone, I have not put much thought into spironolactone until about 16 months ago when I started to really hear an uptick about conversations about Spironolactone. And so the debate that I’ve seen online, which is actually again, this isn’t pet owner for, but it’s interesting, but people are like, if you’ve got Lasix that’s so much stronger, you don’t need spironolactone if you got Lasix. And so let me put that to you as a potential myth that’s out there. How do you feel about that?

Dr. Kristin MacDonald:
I too was educated that it’s a weak diuretic. And really at that time until about a year and a half ago, I’ve been waiting for the data. I like data. I think it’s reassuring. It helps me to know is this worth it or not? And so we’re looking at effects within oftentimes like mitral valve disease and heart failure. And really we’re thinking about spironolactone is not a diuretic. We’re thinking about it kind of like an ACE inhibitor where it’s more of a renin, angiotensin, aldosterone system blocker. So it’s blocking aldosterone receptors. And so we think of it more in that neurohormonal antagonism rather than its effect on increasing urinary output. And there are definitely benefits that have been shown when you add spironolactone to benazepril that these dogs, they had a lot longer time before heart failure worsened and they lived longer and they had less time to what they call at all cause removal or all cause problems. So it’s very safe and effective and we’re learning that it’s not all about just how much urination they’re going to have in diuresis to have an actual benefit. But again, it’s not a one or the other. The beautiful part is that we can use multiple medications at each, have their own job to cumulatively get the benefit.

Dr. Andy Roark:
Well, tell me more about that. Talk to me a bit about quad therapy. So I’m hearing the term quad therapy in our cardiac cases and things. Can you define that for me, is what that means to you and then start to make the case for a quad therapy approach?

Dr. Kristin MacDonald:
Yeah, when I think we all talked about triple therapy, when PMO Bendin became available, we had of course our standard puric amide loop diuretic pulls the fluid from the lungs. We’ve got ACE inhibitors which are blocking the conversion of angiotensin one to two. And earlier studies showed improvement in heart failure class and double survival time. So that was back in the eighties to nineties. Then came pob Bendin, this revolutionary drug that has honestly changed the face of cardiology. It’s made us have a lot more fun and a lot better outcomes.

Dr. Andy Roark:
It should be in the water,

Dr. Kristin MacDonald:
A lot of happy, happy dogs and clients with this drug being an inod dilator. So what we’re looking at is I describe it to owners as this is the one that helps the heart function better and dilates vessels both going out the body and back to the lungs. So this really helps heart failure, many causes. And of course that one demonstrated again, improvement in survival, time and time to heart failure, recurrence, all of that is really something we’re looking for. So now comes on the scene spironolactone, and we just had this best clinical trial that I kind of honestly was waiting for. And what that is looking at is blocking aldosterone receptors with spironolactone and what aldosterone, it’s a toxic neuro hormone. And unfortunately when dogs or cats are placed on ACE inhibitors, we want to believe that there will be less angiotensin too made, which then lessens production of aldosterone. Well, that’s logical, but the body has different workarounds. And so about 40 to 50% of animals people, they have this aldosterone breakthrough where we still have elevated toxic aldosterone circulating in the body that’s wreaking havoc on the cardiovascular system. So we’re looking at now blocking both the ACE system and aldosterone, and I think of it as kind of like peanut butter and jelly, or actually it’d be more like chocolate and peanut butter. For me, the perfect combination really for more comprehensive blockade.

Dr. Andy Roark:
Is it hard to get clients to buy into quad therapy? I mean, we’re talking about giving a number of different medications. If some were to make the case and they were like, it’s better to do fewer things the client will actually do. How do you feel about that?

Dr. Kristin MacDonald:
Very

Dr. Andy Roark:
Tricky. Shoot that down for me if you can.

Dr. Kristin MacDonald:
It’s a tricky, tricky thing. And unfortunately a lot of these dogs are coming to me and have never even seen POB bendin yet. And so they may be on no medications and they come in for a little cough, they think they’ve got kemal cough, things are great, and then I’m telling them their dog is congestive heart failure and may live for a year. This is a lot to handle. So then we start talking about quad therapy, four different drugs. And some clients will get worried like, well, is it safe? Is it toxic drugs might be toxic? Well, yes, we do have to follow kidney values and all, but they are very safe. But then comes the reality of implementation. So how compliant might a client be able to be with four different medications given often twice a day? And unfortunately, doctors, they want to believe they have the perfect pupils that will do everything perfectly.
But I think we may be perfect cases that humans are going to mess up and they’re going to be busy and going to a lot of other stuff on their plate looking at a lot of clients say they cannot handle giving more than three meds. They say, I can’t even do two meds a day. And about 30% said they could give at most three meds a day and that they couldn’t handle more. So I often look at, there’s a nice combination tablet where we have both the NPR and Spironolactone and one tablet given once a day. And so I don’t sneak it in. I just say, well, we’ve got three medications your pet’s going to go home on little. And I sort of say, by the way, one of them happens to have a two in one, so it makes it a little easier for them to handle.
And it’s even easier if they’ve already come in on PMO bendin for preclinical, say, heart enlargement. And then I say, well, we’re just going to add two more medications that are going to help the heart failure part of things. But it’s very tricky. The other part is will the pet take the medication? Maybe the client is absolutely on board. They are dependable. They know they’ve been educated to say, this is how your dog is going to have a good life and live longer, but we have to give the med or it’s not going to work well talking pet language. Your dog or cat may not agree with that, so we’ve got to make sure they know how to give the med. Maybe they may need reminders or training on that. So there’s some great apps out there. I mean there’s apps for everything these days. But I do love the Cardis app because it helps them monitor breathing rights and it has medication reminders and you can have multiple pets. And I do have families that have three animals and heart failure all at once. So just giving them the tools to help them with the delivery.

Dr. Andy Roark:
I love it. Dr. Krista McDonald, thank you so much for being here. You are so wonderful. Where can people learn more from you? Where can they find you online or in the future?

Dr. Kristin MacDonald:
I might be a bit of a dinosaur, but I have a LinkedIn. I don’t check it that much, but really VCA Animal Care Center of Sonoma and LinkedIn. But overall, I also go incognito because online I have a Facebook that’s my own personal Facebook with last namely. Oh, okay. Yeah. But probably through VCA. I am actually going to have a really fun time weekend before school starts. My daughters and I are going to go to Vet Girl U down in Scottsdale at the Princess, and we’re going to have a great time with my mom-in-Law. Oh man. Yeah, you guys should check it out.

Dr. Andy Roark:
Yes, vet Girl u Justine Lee and Garrett Pater are good friends of mine’s founder of Night Girl. Just wonderful people. They’ve got a great event. They have a great culture. I think the world of them. That’s fantastic. Yeah. Awesome. Thank you. Thank you guys. Take care of yourselves, everybody. I’ll talk to you soon. Thank you. And that’s it. That’s what I got for you guys. I hope you enjoyed it. I hope you got something out of it. Real quick before you go, I got to give you a fast heads up. I have a Ray CE webinar coming right at you very soon. It is called The Practical Guide to the Mitral Valve Patient. This is with my friend Dr. Natalie Marks. It is on November 29th at 4:00 PM Eastern. That’s 1:00 PM Pacific. It’s sponsored by Ceva Animal Health. Guys. I’ve worked with Natalie many times. She’s been on this podcast many times. She’s absolutely great, super practical, a really wonderful doctor to learn from. This is going to be packed full of pearls, like I said, free hour race, ce. Jump in and grab it. Link is in the show notes. Get on it fast because this is going to pass us by real quick. Anyway, coming at you. I’d love to see you there, and that’s what I got for you today. Take care of yourselves, everybody. See you later.

Filed Under: Podcast Tagged With: Medicine

HDYTT: Anesthesia on a Full Belly

November 23, 2023 by Andy Roark DVM MS

Veterinary Anesthesia Nerd Tasha McNerney joins Dr. Andy Roark on the podcast to unravel the intricacies of anesthesia on a full stomach. They explore navigating emergencies when surgeries can’t be postponed, highlight crucial factors in devising meticulous anesthetic plans, and dissect the risks tied to regurgitation during anesthesia.

Cone Of Shame Veterinary Podcast · COS – 238 – HDYTT: Anesthesia On A Full Belly

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

LINKS

Veterinary Anesthesia Nerds Symposium 2024

Veterinary Anesthesia Nerds Facebook Page

Veterinary Anesthesia Nerds

Canine Cardiology Webinar (Free RACE CE)

Dr. Andy Roark Resources 

Dr. Andy Roark Swag

REFERENCES

AD Galatos, D Raptopoulos. Gastro-oesophageal reflux during anesthesia in the dog: the effect of age, positioning and type of surgical procedure. Vet Record, 137, 1995: 513-516

DV Wilson, AT Evans, WA Mauer. Influence of metoclopramide on gastroesophageal reflux in anesthetized dogs. AJVR, 67, 2006:26-31

AC Zacuto, et al. The influence of esomeprazole and cisapride on gastroesophageal reflux during anesthesia in dogs. J Vet Intern Med, 26, 2012:518-525

ABOUT OUR GUEST

Tasha McNerney is a Certified Veterinary Technician from Pennsylvania where she works as a educational consultant and relief anesthesia technician. Tasha is the founder of the Veterinary Anesthesia Nerds, while also a Certified Veterinary Pain Practitioner and board member of the International Veterinary Academy of Pain Management (IVAPM) to educate the public about animal pain awareness. In fact, Tasha was the thought leader behind the now celebrated “Animal Pain Awareness Month” within the veterinary industry. Tasha became a veterinary technician specialist in anesthesia in 2015. Tasha loves to lecture on various anesthesia and pain management topics around the globe and was previously named VMX Speaker of the Year.


EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. I’m here with my dear friend, Tasha McNerney. She’s the original anesthesia nerd. Boy, this is a great conversation. Get ready to jot down some notes. I don’t care how much experience you have with surgery and anesthesia, you are going to get some pearls today because Tasha is laying them down thick. This is a great conversation about going to anesthesia when we have a pet with a full belly, and it’s going to happen. It’s just pets don’t always plan to have surgery later in the day when they decide whether or not they’re going to eat. And so this is a thing that we have to deal with. But God, I took so much away from this conversation. It’s a great one, gang. 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, Tasha McNerney. How are you my friend?

Tasha McNerney:
I’m good. Thanks for having me again.

Dr. Andy Roark:
Always. I love having you on here. I just be honest. You and I have been talking for like an hour and we finally had to press record and do this episode, but you are a joy. For those of you who are watching on YouTube, it’s Halloween, just so you know. That’s why-

Tasha McNerney:
That’s why I am dressed like this.

Dr. Andy Roark:
Yes, and for those of you who are not watching on YouTube, Tasha is dressed as, do you want to tell ’em what you’re dressed as?

Tasha McNerney:
Yes. So for all of the Swifties out there, if you’ve ever seen the Shake It Off music video, I am the cheerleader section, the cheerleader, Taylor Swift. So shout out to all the Swifties out there. Not going to lie. I am a Reputation girly way more than a 1989 girly. I know that’s controversial. Oh wow. But the reputation costume that I really would want to have, I need some serious time to work on that. So maybe next year we’ll go a Reputation based costume.

Dr. Andy Roark:
Okay. Well, I mean Taylor has a deep catalog. I think we can just year after year, we can

Tasha McNerney:
Just keep

Dr. Andy Roark:
Going. Just keep going. Alright. I love this. For those who don’t know you, you are Tasha McNerney. You are CVPP which is a certified veterinary pain practitioner. You are a VTS, veterinary technician specialty in anesthesia. You are the founder of the Veterinary Anesthesia Nerds, which was originally a Facebook group, still a Facebook group. However, you have moved way beyond that. You guys have, you’ve had a conference for a number of years. I have heard wonderful things about it. It is all about anesthesia. It has a heavy emphasis on vet techs, which I love, but it’s open to everybody. You guys are doing your next one in San Diego in April, is that correct? April 24?

Tasha McNerney:
That’s correct. Yes. We’re doing April, 2024 and we’re bringing back, we’ve taken a hiatus over the last couple of years with just everything going on and moving in jobs and et cetera. And now we are back and we have some fantastic speakers, not only Darcy and Steven, just wonderful in their own right, but also two great anesthesiologists. Kristen Messenger and Mike Barletta are going to be speaking with us as well. We’re going to get really in depth, really high level anesthesia, new concepts, deep dives into drug pharmacology. But my favorite thing that we do at the conference is the hands-on lab going over head to toe, regional anesthesia, ultrasound guided blocks, different nerve blocks and local anesthetic techniques. So I love that.

Dr. Andy Roark:
I love how you do this. I think the future of learning is this type of really hands-on deep dive when you get together and just really do it. It’s not sitting in a lecture and looking at slides. It is doing the cadaver labs and really doing the skills. Anyway, I love how you guys roll. Also, I love San Diego. It’s a wonderful place to be. You guys are at the Hyatt, which is right on the water and absolutely gorgeous. It’s just, anyway, for anybody who’s looking around and going, man, that sounds amazing. Registration is open. I’ll put a link in.

Tasha McNerney:
Registration is open. Yeah, I can send you the link and we can put it up there. Registration is open. The cool thing about this conference is that we have looked at the data and we know that after a certain amount of time, listen, we all just start to tune out and sitting in a lecture hall for eight hours straight is just a lot. So our lectures are actually from 8:00 AM till 1:00 PM and then our expectation is you’re going to spend the afternoon going out and exploring San Diego. We are really trying to do that work-life balance thing because we want you to actually enjoy your conference and not just see the inside of a conference room. We want you to go outside and explore some stuff. We might be even doing a nerd’s hike where we hike the beach, but also talk about, I don’t know, drug pharmacology as one does.

Dr. Andy Roark:
Totally. So if your boss is like, what will you do in the afternoons? You’re like, I will talk about drug pharmacology. You will while you walk on the beach.

Tasha McNerney:
We will. Sure.

Dr. Andy Roark:
Yeah. Sounds great. Cool. You came to my mind recently because I saw this case and it’s a big dog. I can’t remember exactly what time. It wasn’t a great dane, but I think it was a big shepherd. It was a big shepherd. I remember the hair. I remember hair everywhere. It was definitely a lot of hair. It was a big shepherd. And I saw this dog back after a neuter and it had just blown up. And so this dog had the biggest, most awful scrotal hematoma I had ever seen, like necrotic skin. It was God awful. And I was like, okay, we’ve got to fix this. This dog needs a scrotal ablation. And they brought him in first thing in the morning, and of course I said to them, has he had breakfast? And they were like, oh yeah, he ate everything. And so I thought, you know what?
We need to, we’ll sort this out, but I want to talk to Tasha about anesthesia on a full belly. And also I was like, Thanksgiving’s coming up. I think that’s a good Thanksgiving talk. Is anesthesia on a full belly when I have a full belly, when the patient has a full belly? How does that go? So let me just pause there and we can get into specifics if we want. We can use my one-year-old German Shepherd if we want to, but generally, let me just open the conversation. Tasha, talk to me a bit about putting pets under anesthesia when they have a full belly because it’s going to happen. Ultimately dogs don’t like skip breakfast so they can get hit by a car. That’s not how it works. And so anyway, just start with me a high level. How much of a concern should this be?

Tasha McNerney:
First off, it is a concern. We do know that anytime that our patients do have stomach contents, we are at increased risk for vomiting, but more importantly, regurgitation. And that’s what we really worry about. We definitely don’t want them vomiting. We don’t want ’em feeling nauseous, but we don’t want regurgitation under anesthesia. We know that not only can that cause a problem to the mucosa of the esophagus, but also increases anytime there’s stomach contents, that’s going to increase our chance for a potential of airway, stomach contents, getting into the airway basically. Now you’re mentioning that this patient is going under, is going to go under anesthesia. So let’s just say that when we talk about this from an anesthetic standpoint, the good thing is that we are going to have our airway protected because we’re going to intubate this patient. So having an endotracheal tube in place, having a good seal on that endotracheal tube, testing it to make sure using your capnograph to check to make sure that that seal is appropriate, that is going to help that. If the patient does develop any kind of esophageal reflux under anesthesia, then that airway is going to be protected. So I will say that in this case, if you have a patient come in, whether they be an emergency patient or something like this, where we’re going to do procedure this afternoon and the patient has eaten, then we want to make sure that we are looking at drug choices and setting the patient up for success. There’s nothing we can do to get rid of those stomach contents.
We want to make sure that we are just giving them the safest option possible. And this is why in anesthesia land, we will always advocate for full anesthesia where we can intubate the patient and have control of that airway versus heavy sedation where we might not have control of that airway. And should that patient have esophageal reflux or regurgitation, sorry, that becomes a more dangerous situation.

Dr. Andy Roark:
Let’s just say I’ve got a dog or a cat comes in with some sort of a laceration it, something that needs to be treated, things like that, and you ask the question, when was the last time that your pet ate? And they say, oh, fairly recently. You would actually factor that into is this a heavy sedation case or is this a full anesthesia case? Is that correct?

Tasha McNerney:
That’s correct, yes. And again, that’s going to influence the drugs that we choose. Now, all of our opioids that we are going to utilize and we utilize a lot of opioids, especially if you’re going to surgery with a patient, we know that our full opioids, things like morphine or hydromorphone are going to cause more nausea, more vomiting and more regurgitation, opioids in themselves. Also blunt the protective airway reflexes. There are other drugs that can cause this as well, which are things like anticholinergic. So if you use atropine during your procedure or ace promazine or inhalant anesthetics, and I think sometimes people forget that inhalant anesthetics in themselves can cause nausea, vomiting, blunting that esophageal sphincter tone. So that is something to keep in mind as well. So if you’re going to be utilizing those drugs, absolutely we should have a protected airway and that means intubation of our patient with a good fitting seal that we can verify either with your manometer to check to make sure that your endotracheal tube is holding to the correct pressure or you’re washing your capnograph to make sure you’re getting those nice plateaus. And then we’re not getting any leaking around our airway. We want to make sure that that airway is protected. No stomach contents or regurg can get down into that airway.

Dr. Andy Roark:
I have a RACE CE webinar coming right at you very soon. It is called the Practical Guide to the Mitral Valve Patient. This is with my friend Dr. Natalie Marks. It is on November 29th at 4:00 PM Eastern. That’s 1:00 PM Pacific. It is sponsored by Ceva Animal Health. Guys, I’ve worked with Natalie many times. She’s been on this podcast many times. She’s absolutely great. Super practical, a really wonderful doctor to learn from. This is going to be packed full of pearls, like I said, free hour RACE CE. Jump in and grab it. Link is in the show notes. Get on it fast because this is going to pass us by real quick. Anyway, coming at you. I’d love to see you there. Let’s get back into this episode.
Talk to me a little bit about the approach that some people have of, Hey, this pet’s got a full stomach. We’re just going to use our opioids, we’re going to use morphine, we’re going to use hydromorphine. They’re almost certainly going to throw up, and then we’ll go ahead and do our procedure. You pointed out some things to be concerned about or at least pay attention to with our opioids. Do you hate that approach? Are you okay with that approach? Talk to me a little bit about how you feel about that.

Tasha McNerney:
Yeah, so interestingly enough, my husband, who I should let people know, my husband works in vet med, so when I say I was talking with my husband about something similar to this, he was like, but I would want to give them hydro and dexmed. Then I know they’re going to throw up all their stomach contents.

Dr. Andy Roark:
Yeah.

Tasha McNerney:
Potentially. Yes, potentially that’s true. And this is again, where I have to say every single patient is going to be treated differently because if you said to me, I have a laceration repair on this bulldog, French bulldog, Boston Terrier, boxer, anything, brachycephalic, again, because of their body confirmation, just because of the breed, I know that they are already at a higher risk of vomiting, regurgitation under anesthesia. So if we heavily, heavily sedate them with something like an opioid plus minus dexmedetomidine, even acepromazine, then what I worry about is if my team isn’t on top of it, could they potentially be vomiting but then not be in a position I’m talking about with their body. If they’re on the side, they’re vomiting or if they vomit up and then immediately fall over, we’re not ready with intubation to protect their airway. There is a chance that some stomach contents could get into their airway, and we are at greater risk of aspiration pneumonia. So if this is a brachycephalic breed, I will really try to avoid making them vomit before I am ready because I don’t want them potentially getting anything into their airway.

Dr. Andy Roark:
Yeah, that absolutely makes sense. And as you’re sort of laying this out, I was like, yeah, this is the stuff of nightmares. Yeah, that totally makes sense. So looking at brachiocephalic breeds things like that’s going to specifically or that’s going to increase your concern?

Tasha McNerney:
Yes, 100%. So if this was a shepherd that came in, and again, every patient is an individual. So if you said to me, Tasha, I can’t even get a catheter in without giving this patient some sedation, then again, what we have to look at is what’s the procedure that’s about to be performed? How heavy of analgesia and sedation do I need for this patient? So if I have a shepherd that is in for a scrotal ablation, I know that they have eaten within the past couple of hours, then we have to look at can I get a catheter in? If I can get a catheter in, then we can give our drugs IV. And we know by giving our drugs IV opioids, IV dexmedetomidine IV, we can lessen the overall amount that we’re giving and then that will lessen the side effects. And we usually don’t tend to see if we have given something like hydromorphone or buprenorphine IV, we don’t tend to see the same amount of nausea, vomiting, et cetera, that we will with an IM or subcutaneous injection.
So if I can get IV in, that’s preferred. However, if you say to me, absolutely, this dog is going to need some sedation before we place a catheter because it’s extremely fearful and reactive, then okay, let’s do that. Now, my drug choices might be a little different. Maybe I might choose something like buprenorphine or butorphanol as my opioid plus minus a dexmedetomidine or acepromazine. Again, depending on the patient’s, ASA status health status. So I might give that as an IM injection just to sedate the patient enough to do an IV catheter. And I know there’s people out there saying, Tasha, you just said butorphanol. Butorphanol is not a potent analgesic. I worry if I give butorphanol, then can I still give an opioid? Yes, butorphanol as far as its analgesic properties, pretty short acting. So let’s say you gave that patient butorphanol as a sedative because we don’t want to give it morphine or hydromorphone.
I don’t want it to be vomiting all over. So let’s give it a little butorphanol, less likely to vomit and then say the time goes by, you can always top off with IV hydromorphone or IV buprenorphine. Okay, yes, some of the receptors are going to be taken up with the butorphanol, however, not all of them are. So layer in your other opioids, once you get that IV catheter in place, our other opioids like hydro are going to be fast acting. If you have fentanyl at your practice, you could consider that as well of the opioids. Morphine is going to be the one that causes the most vomiting and of the pure MU opioids, methadone is going to be the one that causes the least amount of vomiting. If you have access to methadone, again, for a GI case or something, that’s usually what I’m going to go towards. However, if you’re at a practice that doesn’t have any MU opioids, then you have to use what you have on the shelf, and that’s when I start to look at things like butorphanol and then follow it up with longer lasting, higher level analgesia with buprenorphine.

Dr. Andy Roark:
Okay. No, that totally makes sense. And yeah, I’ve got to tell you, starting off with a buprenorphine or sort of a partial agonist and then adding in more of a pure agonist, that’s not a tool I really have in my toolbox. I have to sit with that. So is that a fairly common procedure? Are there things that you should be concerned about? Do you see, I don’t know. When you start with something that’s sedative and then you add an IV pure opioid on top of it, so start with buprenorphine and then add in some hydromorphone IV. Again, I just don’t have a lot of experience with that combination in my hands. Is there anything I should be looking out for or anything that I want to pay attention to?

Tasha McNerney:
Yeah, no problem. So I’ll just clarify that. If I was going to do this where I needed a sedative at first, I would be using butorphanol, not necessarily buprenorphine. Buprenorphine in itself of the opioids is not going to cause a lot of good sedation. So if I’m looking at a patient where I just need some sedation to get me through to get a catheter in place butorphanol is where, that’s where you want to go. Again, if I’ve used butorphanol say 45 minutes to an hour beforehand, and now I’m about to induce anesthesia and I need some analgesia and I’m about to give hydromorphone, yes, you potentially could not see as strong effects with your hydromorphone. However, as with any anesthetic or any analgesic protocol, it’s not all about the opioids. We want to make sure that we’re using a multimodal protocol so that way if there are some receptors that aren’t able to be taken up with the hydro and those MU receptors aren’t able to be fully agonized with our hydro, well that’s okay because guess what?
We’re also adding in things like maybe a Lidocaine CRI. We’re using regional anesthesia to our fullest extent. We’re adding in dexmedetomidine together with opioids, a really wonderful sedative analgesic combination. I think, again, if anybody’s ever heard me speak how much I love dexmedetomidine, and even the addition of half a mic to one mic per KG IV dexmedetomidine is going to provide additional synergistic analgesia. So I think that if you are at all worried that maybe my hydro is not going to work as well because an hour ago I gave butorphanol, that’s fine. Again, you’re going to do a multimodal protocol. We’re not always just going to rely on our opioids, and if we look at some of the evidences from human medicine, it really is about playing with and being very careful with or targeting our opioids, maybe even reducing our opioids and increasing some of these adjuncts like dexmedetomidine lidocaine, regional blocks, et cetera.

Dr. Andy Roark:
Is there any chance that you’re going to see a bounce phenomenon? So you use Butorphanol, which has got a pretty short half-life, and I give my hydromorphone, am I going to see increased effects from the hydromorphone after the butorphanol wears off, or is that not going to happen?

Tasha McNerney:
No, not usually, or at least we don’t seem to appreciate that again, because usually these patients are now under the effects of inhalant anesthesia.

Dr. Andy Roark:
Okay, so we’ve talked about choosing our opioids and what that looks like. Talk to me a little bit about GI protectants, things like that.

Tasha McNerney:
Yes, excellent. Because again, if I have a patient that came in and they needed an emergency surgery, let’s say they have a fracture or whatever, they have the laceration repair, they have eaten. I’ve chosen the most appropriate opioid. We have a catheter in. Now, another thing that’s going to be important, again, because we know that these drugs that we’re using like opioids, like inhaling anesthetics, are going to blunt those reflexes and they are going to decrease the sphincter tone or esophageal sphincter tone. Then we want to make sure that we are putting GI protectants in, and this is things like pantoprazole, omeprazole, metoclopramide, not only the bolus of metoclopramide, but also then a CRI of metoclopramide. So things like this, if I know that patient is going to surgery and they’re going to get opioids and inhaling anesthetics, I know that they’ve eaten in the last four hours, I’m going to my clinician and I’m saying, okay, also before we get started with inhalant anesthesia, once we get that catheter in, how do you feel about pantoprazole?
How do you feel about maybe some cisapride omeprazole? Do you want me to start a reglan CRI? Things like that. We do have some evidence that doing these things is going to decrease the amount of esophageal reflux under anesthesia. Then another thing that I want people to know is if you as the anesthesia technician are with a patient and they’re under anesthesia and you notice that they do have regurgitation either coming out of their mouth, coming out of their nose, et cetera, that’s really important to note. You want to let your clinician know that because that pH of those gastric contents that are coming up, that’s acidic. So we risk damaging the mucosal layer of the esophagus. So not only do we want to make sure we alert our clinician, write it down on our anesthetic record, but also it’s going to be important to not only have your suction ready, but you’re going to want to lavage that.
Now, there was a study looking at whether or not just plain saline versus saline with diluted bicarbonate was better to reduce that pH in the mucosa, and they did find that if you’re going to lavage the esophagus, then you want to make sure that you’re using saline with diluted bicarbonate in it to neutralize that pH, and then you have your suction ready, suctioning all of that out. Also, one thing that you want to note is, again, on your anesthetic record, we want to make sure that we know that this patient did have some regurgitation intraoperatively, because then I might want to talk to my clinician about whether or not this patient should be started on something like sucralfate once they have their swallow reflex back.

Dr. Andy Roark:
Yeah. Alright. That totally makes sense. Great. I feel good about this. Is there any other things I need to look out for? Any words of wisdom, pieces of advice?

Tasha McNerney:
No. Well, interestingly enough, the patients that do have the highest amount of regurgitation under anesthesia are orthopedic patients. So again, if your patient is a orthopedic fracture repair, then they actually already have a higher incidence of having that regurgitation, so be prepared with your GI protectants.

Dr. Andy Roark:
Why do you think that is?

Tasha McNerney:
I don’t know, but it was a really interesting study. I can send you the paper if you want to put it in the show notes. Yeah, sure. Send. But they look like they saw that orthopedic patients actually had a 25% chance greater incidence of esophageal reflux and regurgitation than the other patient populations. It’s very strange. Oh,

Dr. Andy Roark:
That’s fascinating. Cool.

Tasha McNerney:
And again, again, so brachycephalic already have an increased risk of regurgitation under anesthesia, so make sure you are protecting their airway at all costs.

Dr. Andy Roark:
Yes, I love it. Awesome. Thank you so much for talking through this with me. I have a page and a half of notes from a 15 minute conversation, absolutely enjoyable. I really appreciate your time. I will put links to the anesthesia nerds conference up. Tasha, where can people find you online?

Tasha McNerney:
Yeah, we are on the veterinary anesthesia nerd, so veterinary anesthesia nerds.com is the website for all of our information where you can find all of us speaking. And if you really want to get involved in the chat where our chat is mainly going over cases still as a Facebook group, but a very active Facebook group. We are looking to move off of Facebook in the near future and just be located on our website. But for now, you can find us on Facebook, you can find us on Instagram, and come see us in person in San Diego.

Dr. Andy Roark:
That sounds awesome. Awesome. Thanks so much for being here, guys. Thanks for tuning in. I hope you learned something. I hope you took something in the way. Take care of yourselves, everybody.

Tasha McNerney:
Bye.

Dr. Andy Roark:
And that’s it. That’s our episode. That’s what I got for you. Thanks, Tasha, for being here. Guys, thanks to you for tuning in and listening. Take care of yourselves, everybody. We’ll talk to you soon.

Filed Under: Podcast Tagged With: Medicine, Vet Tech Life

Mastering Weight Management

November 13, 2023 by Andy Roark DVM MS

Dr. Taryn Pestalozzi, DVM, residency-trained in Nutrition, joins the podcast to talk about how she approaches difficult pet weight-loss conversations. Dr. Pestalozzi and Dr. Roark discuss the case of an obese Labrador Retriever named Greta, and how best to handle her care. As a veterinarian who practiced in GP for 7 years before running the Healthy Weight Clinic during her internship at Kansas State University’s Veterinary Health Center, Dr. Pestalozzi has fantastic and practical insight on how to motivate pet owners to make real changes for the sake of their best friends.

Cone Of Shame Veterinary Podcast · COS – 236 – Mastering Weight Management
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This episode is brought to you by Hills Pet Nutrition!

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LINKS

The Hill’s Veterinary Academy is a one site solution for educating the entire veterinary team. On the HVA, you can find FREE RACE CE from leading specialists and experts, patient-centric education beyond nutrition and flexible, on-demand content that fits your schedule. 

Hill’s Veterinary Academy: https://na.hillsvna.com/

Hill’s Body Fat Index Tool

World Small Animal Veterinary Association Nutrition Toolkit

Association for Pet Obesity Prevention

Pet Nutrition Alliance Calorie Calculator

Ohio State RER Calculator

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Taryn Pestalozzi received her bachelor’s degree from Smith College in 2008, before graduating with her DVM from Oregon State University in 2013. Dr. Pestalozzi was a general practitioner in the Portland, OR metropolitan area for 7 years before completing a clinical nutrition internship at Kansas State University’s Veterinary Health Center, where she managed the Healthy Weight Clinic. Dr. Pestalozzi recently completed her clinical nutrition residency at UC Davis Veterinary Medical Teaching Hospital.


EPISODE TRANSCRIPT

Dr. Andy Roark (00:07):
Hello and welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great one for you. Today is on mastering weight Management. This is super mega practical, what to say and how to say it. Podcast, I have got Dr. Taryn Pestalozzi here. She is residency trained in nutrition. She’s a joy to talk to. She is super practical and pragmatic, which I really love. She’s got great advice for setting up these weight management conversations in a way that actually get results and help us convince pet owners to make the steps they need to make to take care of their pets. Anyway, you are going to probably get some affirmation for things that you do out of this, you are also going to get some tips and tricks for things that you don’t do or ways to have these conversations that you haven’t had.

(00:55):
I am really big on this. I love it when we get insights on things that we do a lot of because little tweaks in those behaviors make a huge difference because we do ’em all the time. And so anyway, this episode is really good and it’s really useful. I think you guys are going to really, really like it. I have to say thanks to my friends at Hill’s Pet Nutrition for making this episode possible ad free. And I also have to say thanks to ’em for their Hill’s Veterinary Academy. Guys, if you have not checked out the Hill’s Veterinary Academy, it is a fantastic learning platform that Hill’s is putting out and they are steadily growing and expanding and it is packed full of good stuff for training your team. It’s got free RACE CE in there. There’s so much that’s going on and they’re really putting a lot of effort into it. So anyway, if you are not familiar with the Hill’s Veterinary Academy, I’m going to put a link down in the show notes. You can give it a Google if you want to go that way, but check it out. Go see what they’re doing. This is really just a neat little gift through our profession. So anyway guys, that’s enough of that. Let’s get into this episode.

Kelsey Beth Carpenter (01:55):
(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 (02:12):
Welcome to the podcast, Dr. Taryn Pestalozzi. How are you?

Dr. Taryn Pestalozzi (02:16):
Good. Thanks for having me.

Dr. Andy Roark (02:17):
Oh, I am so glad that you’re here. I am looking forward to this. So, what I wanted to talk to you about today, so when you did your internship, you did your internship at Kansas State and you ran the healthy weight clinic there and I see a lot of very heavy pets. I saw a cat that was rapidly gaining weight last week and it bothers and this is a passion of yours. It’s something you have a lot of experience in. I just want to run through a healthy weight campaign with you today and just be like, alright, tighten. Let’s tighten the bolts down here and I want to make sure that I’m running a program and then I can carry this out and I want to get weight off of pets and so are you okay to run through a case with me and just start to finish and get me set for success?

Dr. Taryn Pestalozzi (03:22):
That sounds great. Let’s do it.

Dr. Andy Roark (03:24):
Let’s do it. I have got a 100 pound female spayed chocolate Labrador named Greta. So Greta is eight years old and those hips ain’t what they used to be. Sure not. And I can see it. I can see that the muscle mass in her back legs is not what it used to be. And owners are not reporting mobility issues. She’s not, her gait doesn’t appear to be, you don’t see her walking going, oh boy, but she’s eight and I can see that when I look into my future scope where I look ahead a year or two. And so this dog is probably 20 pounds overweight. I think she should be, honestly, if I’m really serious, she should probably be a 75 pound lab, but she’s a hundred. I could be okay. I think if she’s 80, I have to see it. You know what I mean? And you go,

(04:23):
I think 80 is about right. I have to see it, but I need some help in this. And I think that I can get the owners motivated, they love this dog. I think I can make a solid pitch for the lack of mobility that’s coming down the pipes and I want to really push and so I have not gone into this room yet, but I want you to help me. That’s how the table is set. Taryn, how do you treat this case? Where’s your head at when you’re standing outside this door to the exam room getting ready to go in?

Dr. Taryn Pestalozzi (04:55):
So I think the first thing is maybe keeping in mind maybe these owners haven’t come to see you for this problem. They’ve brought Greta in for her annual exam. Yeah, she’s in needs. So it can sometimes take people off guard when you bring up a topic and you get really fixated on that that they weren’t really coming to talk about. So first thing I think is to not forget your primary reason for the appointment. And if you need to schedule a follow-up to actually spend more time talking about the weight loss, do that. But then also consider asking permission to talk about her weight. Be thoughtful with your language. Don’t use fat humor. There was a consensus statement that came out of the UK between medical professionals and the human medical side and patients from obesity programs that talked about what kind of conversations and language are useful. So some of those tips are coming from that consensus statement sort of extrapolated that to our veterinary friends. So just be mindful that as you go into have this conversation.

Dr. Andy Roark (05:53):
Okay, talk to me a little bit about asking permission, right? Give me some language. I know we’ve had a lot of doctors who, and there’s a lot of technicians that are coming in and taking a history and they know that I’m going to come in and talk about the weight and it would be helpful to me if they could open this conversation up. So give me an example of what that, asking permission, I get the concept, what does that sound like?

Dr. Taryn Pestalozzi (06:12):
Yeah, I would start with an open-ended question probably. So asking the client how do they feel Greta’s doing overall? Do they have an idea of where they think she is in terms of weight? Do they think she’s a healthy weight? Do they have any concerns that she might be over or underweight? And that lets you also assess maybe where they’re at with that topic and then ask them, do you mind if we spend some more time talking about this today? I think I have some concerns.

Dr. Andy Roark (06:40):
I really like that question of do you have any concerns about her being over or underweight? It feels like a standard sort of form question and it’s not a judgment question. It feels like I’m taking a history or I’m filling out my form and it helps me know really quickly do they see it or are they blind to it? And we’ve seen, I mean I literally had a case just like this one chocolate lab a hundred pounds and the owners just could not see it. And I was showing them the body condition out and they didn’t get, that was rare. Definitely happened. I still remember it. They were just like, Nope, she looks like a five of nine to us and I’m just going, we’re not looking at the same things.

Dr. Taryn Pestalozzi (07:19):
Yup.

Dr. Andy Roark (07:19):
Anyway, a great question. Alright, I love it, Taryn. That’s super helpful. Alright, great. So I get get this conversation, get permission to talk to them about it. I like it. Let’s say that they’re like, sure we’re here for our annual exam, wellness, yup, we’ll totally talk about it. Where do you start to go from there?

Dr. Taryn Pestalozzi (07:39):
Yeah. Next would, as part of my exam I do a body condition score assessment on Greta and I think most of us are familiar with the body condition score concept. There’s a couple of different scale systems out there, so there’s a five point scale, there’s a nine point scale in the nutrition world, we tend to go with that nine point scale and if you need a resource in your clinic, the world’s mono, that association has some nice non-branded charts that you can use, but there’s lots of them available and I keep a copy in my exam room laminated and I actually pull it out and I look at it while I do my body condition score because the more you actually read through the definitions of what each of the points on the scale mean, the more consistent you will get. And also if you have your support staff and the other clinicians in your hospital all using that same tool and actually looking at it, you’re going to be more consistent across your whole clinic so that you start building a more reliable history as you’re seeing patients.

Dr. Andy Roark (08:35):
I tend to run into not opposition to this conversation, but just a level of passiveness that they don’t argue with you. They’re not like, no, we’re not going to do a weight loss program. But non-committal I think is how I would

Dr. Taryn Pestalozzi (08:57):
Yeah

Dr. Andy Roark (08:57):
And again, I’m going to lean into the hips in this case and try to make a real quality of life point here, but as I try to motivate for action and try to push through that non-committal place to get them on board with taking action, how can you support me there?

Dr. Taryn Pestalozzi (09:18):
Yeah

Dr. Andy Roark (09:18):
How do you do that?

Dr. Taryn Pestalozzi (09:20):
I think it’s common for a lot of us to maybe focus on those negative outcomes that we are sort of foreseeing in the future. And there’s certainly clients that might need that, right? They maybe need you to really kind of hone in on those negative potential outcomes because they might not budge without it. But going back to that consensus statement in human medicine, it’s actually more effective a lot of times to focus on positive outcomes of weight loss rather than the negative potential consequences of being overweight or obese. So I hear from clients all the time, even with minimal, it’s pretty small amounts of weight loss. They’re acting so much younger, I can see they look thinner. I’m getting compliments on how they look. I’ve had to make their harness smaller. And so really focusing on what the benefits are and what they might see as that progress happens, I think is often more motivating.

Dr. Andy Roark (10:14):
I like that. So what your counsel here would be in the case of a dog that’s overweight and a senior pet is maybe don’t, ooh, she’s getting older, but instead talk about what we could accomplish and she could have the best years of her life. I mean there’s quite possible we could turn back the wheel of time a couple of years and you would see her

Dr. Taryn Pestalozzi (10:35):
Sure, let’s give her the best quality of life where we can as long as possible. And to do that, let’s really focus on getting her down to a lean ideal body condition so that she can be mobile as long as possible and do the things that she loves.

Dr. Andy Roark (10:47):
I’d much rather have the positive conversation than the negative one. No one wants to go tell someone, I’m really worried your dog is going to get worse and have hard time getting up. And that’s not a fun conversation.

Dr. Taryn Pestalozzi (11:00):
No, it’s not at all.

Dr. Andy Roark (11:00):
Appreciate this perspective. I like this so motivating from here to hear to action. I do like that. Any other advice for trying to get buy-in and build momentum?

Dr. Taryn Pestalozzi (11:11):
I think it’s important to try to get all of the humans in the household on the same page. There’s always going to be that person who maybe causes lack of compliance, sneaking treats or they don’t see the importance of the plan. So trying to get everybody involved in that conversation and on the same page is always a good idea if you can, it’s not always possible, but I think that’s going to be helpful for your success.

Dr. Andy Roark (11:40):
What does that look like when you go into the exam room? Because it’s always like my husband does and he’s not there.

Dr. Taryn Pestalozzi (11:50):
They throw each other under the bus. Right?

Dr. Andy Roark (11:52):
Business. That’s totally true. It could a hundred percent not just because they say it’s the person who’s not there. That doesn’t mean that really is.

Dr. Taryn Pestalozzi (12:00):
Sure. I’ve had clients pull me aside, tell me to kind of tell on their spouse or their partner. So I think if you can have ’em both in the same room, maybe you do have schedule a follow-up appointment and ask if they can both be there or I’ll be there. But otherwise, I mean I’ve had clients ask me to write letters to their significant others on letterhead to tell them they need to stop feeding the pet. I haven’t had that as much since I came to nutrition, but I was a GP for seven years before I did nutrition, so I definitely got that apps that several times

Dr. Andy Roark (12:31):
Oh that’s so funny. Alright.

(12:33):
Got it.

Dr. Taryn Pestalozzi (12:34):
I mean you kind of have to play it by ear, but I think trying to get buy-in from everybody is useful.

Dr. Andy Roark (12:39):
Oh, I love it. I just wondered if you had some special tool like I video myself and text it to them. I don’t know. I don’t know. I was just curious if you had any tools for wrangling people in.

Dr. Taryn Pestalozzi (12:48):
Yeah, we do the best we can.

Dr. Andy Roark (12:49):
I love it. This feels so daunting. 25 pounds is a lot. I mean 20 pounds, it’s a lot. 20 pounds per person is a lot and a person weighs more than a hundred pounds. Generally it’s a lot to lose. We’re talking 25%, 20, 25% of this pet’s entire body weight. How do set, it’s not going to be done in a week. This is going to be a process. How do I set expectations so that the clients are not like we’re going to try hard for five days and then I don’t see any changes I’m giving up, help me set us up for success in this and what’s going to be a marathon?

Dr. Taryn Pestalozzi (13:33):
Yeah, I think that’s a really good question, a thing to consider. So there’s a few things. First, the Association for Pet Obesity Prevention puts out annual reports that do surveys of both veterinary clinics and pet owners. And on the most recent data from 2022, they reported on average maybe 30 to 40% of pet owners who had tried a weight loss plan either reported their pet was not successful or they even gained weight. So trying to mitigate that is going to be helpful for long-term compliance. So the first thing is being specific in your recommendations so that you are setting them up for hopefully success right away and not sort of initial lack of weight loss, ribbon weight gain. We can’t always prevent that. So I do warn owners this is a process, it’s going to take us a while. We might backslide occasionally, but we will hopefully be moving forward the majority of the time. I think the second thing is coming up with a timeline. If Greta is a hundred pounds, let’s say that she is, I don’t know, 20% overweight, so she’d be a seven out of nine. For example, if our goal’s a five, so she’s actually 20 to 30% overweight as a seven out of nine. So then we can say, okay, well she’s 20 to 30% overweight and she loses on average 1% per week, which would be the bottom of our target range, then it’s going to take us at least 20 to 30 weeks to get her down to ideal weight. And that’s on an ideal sort of situation. It often takes longer. So giving them a timeline of what to expect I think is helpful.

(15:12):
Then the last thing is just really monitoring so that you can be making adjustments to the plan. I normally see these patients ideally every two to three weeks, or if I’m not seeing ’em in person, I’m at least doing a virtual check-in appointment. I’ll have them weigh them on their own and send me the wait before the appointment and then we can spend maybe five to 10 minutes on the phone or on a video call having that conversation of what’s next, what adjustments do we do or not need to do, what do we need to troubleshoot? And that way we’re keeping progress moving forward hopefully and not running into plateaus that just continue on and on and on.

Dr. Andy Roark (15:48):
Yeah. Okay. I got a couple of questions, so I really like this. So tell me what a specific recommendation sounds like when you say that. How far down the rabbit hole are you going as far as the specificity of what you’re giving to?

Dr. Taryn Pestalozzi (16:03):
Yeah, well, I mean as a GP was totally guilty of this, and I know lots of other practitioners do this too, of they’re overweight to say, oh, just drop their food a quarter of a cup, right? Yeah.

(16:14):
And we go, okay, great. We’ll see you in six months for your net set of vaccines, have a good life, whatever. And instead, what really we should be doing is giving a specific feeding amount. So the first thing is, as much as we can getting an accurate assessment of how much the pet is currently eating, so all the food they’re getting, any treats, any foods they’re going to use to give medications, which often clients forget to include in that history when you ask. And from there, I normally would drop their intake probably 20% initially if, I don’t know if they’re the kind of client who says, oh, well I feed the green bag, it’s really expensive so I know it’s good quality and I just fill the bowl up every two days. Well then I would start for a dog with their resting energy requirement and if they’re a cat, I’d start at 80% of the resting energy requirement.

(17:02):
There’s two methods, so a lot of nutritionists will use an estimated ideal weight to do those calculations and that’s great. That’s how I did it when I ran the Healthy Weight Clinic at K State for that year, and it’s definitely a successful method. That’s also what AHA has in their weight management guidelines. At Davis, we do things a little bit different. We use their current weight, not an estimated ideal weight. We want to use a true number and not an estimate to make all of our calculations. Both methods work really, you’re just picking a starting point and you’re adjusting from that starting point. The other thing we do is we recommend they weigh their food in grams, or if it’s canned food, then at least an easy fraction of a can because we want to be as accurate as we can so that we can make small adjustments as we go.

Dr. Andy Roark (17:46):
Okay. Yeah, that totally makes sense to me. I like the timeline idea as well. I think that’s part of the recommendation. It’s funny when you say 1% per week, I go, okay, well that’s six months, which feels very different. And just saying out loud, this is minimum of six months, just so you know,.

Dr. Taryn Pestalozzi (18:05):
That’s like best case scenario. If there is six out of nine, I can probably get them down to ideal and figure out what it takes to keep them there in about six months. If they’re seven or above, realistically you’re talking more like nine to 12 months or more.

Dr. Andy Roark (18:19):
Yeah.

Dr. Taryn Pestalozzi (18:20):
They’re that 11 out of nine, maybe you’re talking 18 months. So it’s not a short process. It does take a dedicated owner and that’s why you have to be their cheerleader and positive reinforcement of the owner. You’re doing a great job. I’m seeing improvement. Let’s keep going. We give prizes. When they reach their target weight.

Dr. Andy Roark (18:38):
What kind of prizes do you give?

Dr. Taryn Pestalozzi (18:40):
Well, at Kansas we took a photo of them and we were going to make, this was right as I was leaving, we were going to make a wall of fame. So I dunno if that or wall of success kind of oncology departments like to do with their pets finished chemo and then I would give them slow feed bowls or leashes or frisbees, that kind of stuff. If we had plants who are really hesitant to weigh their pet’s, weigh their food, we actually had some gram scales and we would just give them one

Dr. Andy Roark (19:07):
Wow.

Dr. Taryn Pestalozzi (19:07):
Say, can you please just do it? I didn’t do that for everybody, but it was like I was getting a lot of pushback. Yeah.

Dr. Andy Roark (19:13):
Well it shows how serious you are about it, for sure.

Dr. Taryn Pestalozzi (19:16):
Yeah.

Dr. Andy Roark (19:17):
Talk to me a little bit about what these, so I really like sort of the monitoring part. Talk to me a little bit about what these monitoring recheck appointments look like. So you’re like, yeah, we see ’em back two to three weeks. First let’s talk in person. But I think the virtual is, there’s a lot of opportunity there, but just if you have them sort come back into the clinic, what does that recheck look like? I know everybody’s busy, you know what I mean?

Dr. Taryn Pestalozzi (19:37):
Sure, yeah.

Dr. Andy Roark (19:37):
So we’re trying squeeze it in. What does that experience for the clients look like?

Dr. Taryn Pestalozzi (19:42):
So it can be a quick appointment. So my sort of rule of thumb is if I’ve made any changes to their plan, I try to see them back in two to three weeks. If we haven’t made any changes, I push it out like a three to four weeks. So on average every three weeks or so, and it could be probably at the most a 15 minute appointment if you are sort of efficient in how you’re running it, if you’re leveraging your support staff so you could have your support staff go in and body condition that animal if you’ve gotten everybody well trained and on the same book in that regard, get a weight and take a little bit of a diet history. How have things been going? Are you feeding them out? We talked about last time, have you run into challenges? What sort of troubleshooting?

(20:21):
I mean, I think the classic example I give to students is they come in and they haven’t lost any weight and it’s December and you find out that, oh, the in-laws are in town visiting for the holidays and they’ve been feeding the dog a ton of milk bones, so maybe we don’t need to make a change that visit. Maybe we just need to send the in-laws home and get back on track. But if they have kind of lost in that one to two-ish percent percent of body weight per week, then great, we don’t make any changes. We see you again in a few weeks, reassess. If they have not lost as quickly as we’d like or they’ve gained weight, then I’d probably drop them about 10% of their daily caloric intake.

Dr. Andy Roark (21:03):
Okay.

Dr. Taryn Pestalozzi (21:03):
They’re losing too fast, then I’d up ’em 10% and I’d see ’em again in two to three weeks and we’d reassess at that point. And I keep in mind treats. So we plan for treats in our plans. Yeah,

Dr. Andy Roark (21:14):
Gotcha. Talk to me about what losing too fast looks like. So that’s what I was going to start to poke you about a little bit was like when they come back in two to three weeks, what are we looking for? And definitely, I like the idea that we’re going to put ’em on a scale. We’re going to put ’em on the same scale they used last time, so we get some consistency and then if we’re not seeing any weight loss at all, we’re going to start to adjust. And that all tracks to me, when do I have to start worrying like, oh, we’re falling like a stone? Because I suspect that pet owners are probably pretty psyched. They’re like, this is great. We’re making real headway. Greta’s not really thrilled, but the pet owners, I could see them being on board. What am I looking out for there?

Dr. Taryn Pestalozzi (21:56):
Yeah, I mean I’ve had that happen. It’s less common than you might think, but I mean, I’ve had dogs that got boarded when they were sort of starting their plan and they lost like five, 6% in a short period of time, like 10 days. And so our concern there is two things for both species we’re concerned about lack of muscle, muscle losing lean muscle. You mentioned Greta, you were concerned about the muscle in her hind end. So that’s great. I would encourage everybody to actually record a muscle condition score every visit. It doesn’t have to have a number. The world’s Monolo Bed Association actually doesn’t use a numerical scale. It’s just normal or mild, moderate or severe atrophy. And then I’d also be concerned maybe in our cat patients about something like hepatic lipidosis, but that takes a lot. It takes very dramatic sort of extended in tants or hypoxia to get hepatic. So I don’t get too worried about it. But certainly for our cat patients, if I’m starting a new plan, I am really conscious of how I tell owners to transition ’em onto a new food and give them criteria for when they would need to call us. If they’re not eating the new food or they’re not doing well,

Dr. Andy Roark (23:04):
How does the virtual check-in visit work? Because if they’re not there and you don’t have your scale, what is that experience like for the pet owner?

Dr. Taryn Pestalozzi (23:11):
Yeah, I mean it’s a pretty similar, I think outline to how the appointment runs. But what I do is I made a little handout for my owners that shows them some specific photos. I want them to take the photo from the side, a photo from above, and then one of their face if you want to use the body fat index tool from Hill’s and University of Tennessee, I’d also take a picture from behind them staring at their butt. And that lets me just assess roughly their body condition or their body fat index. And then I have the owners weigh them and I just tell ’em, find a consistent way to weigh them, whatever that is. They’re coming to your clinic just for a quick swing by the lobby scale. Or if they have a scale at home, they can get an infant scale or even a floor scale for a big dog relatively inexpensively online. And so they just email me in advance their weight, they send me their photos. I can do the math that I need to do right before the appointment, and then it takes 10 minutes or less to have that conversation about do we need to troubleshoot anything? How fast or how slow were you losing weight? And what adjustments do we need to make?

Dr. Andy Roark (24:14):
Got it. Perfect. That totally makes sense. Good deal. I like this. This seems good. Are there, so we’ve got a plan, we’ve got some good motivators, we’ve got specific recommendations. We’ve got a follow-up plan. I really like the ongoing monitoring. That makes a ton of sense. I a hundred percent see how I can lean on my technicians to help me with this and to run this program. That’s a big deal to me. I really like nutrition for technicians and they can make my job really easy and we can make a real impact together. But anyway, so I like all this. Is there any final pearls pieces that I want to make sure that I’m not forgetting

Dr. Taryn Pestalozzi (24:54):
And I maybe skipped over it? So in our specific recommendations,

Dr. Andy Roark (24:58):
mm-hmm

Dr. Taryn Pestalozzi (24:58):
the majority of these patients should be on a therapeutic, a prescription weight loss diet because if we start restricting their calories, especially if they get below RER or even 1.2 times RER, if we’re talking about dogs, we can cause nutritional deficiencies if we feed a non-therapeutic diet for a long time because those therapeutic diets are fortified with extra protein and vitamins and minerals to account for the lower calorie intake that those pets are having. They also help them with stain full, so satiety, if they’re canned diets, they have a lot of moisture. If they’re kibble, they might be what they call air puffed, so bigger kibbles to take up more volume. And then they also often are high in fiber to help them feel full. So you really should be using a diet like that if you’re going to institute a weight loss plan unless you’re doing small amounts of weight loss and you’re being very conservative with how fast you push them.

Dr. Andy Roark (25:50):
Okay. Define RER for me real quick.

Dr. Taryn Pestalozzi (25:53):
Resting Energy Requirements, and there’s a couple ways you can calculate it. I’m going to give some resources I think at the end that we’ll show you how to do all the calculations and walk you through how to do a plan like this.

Dr. Andy Roark (26:05):
Cool. I love it. And then I want to dig into this a little bit. I think that’s a great point about moving to therapeutic D because one of the pushbacks I always get is, well, I can just, there’s a light version of what they eat. Can I just use the light food? And I want to be supportive of pet owners and kind meet ’em where they are. And at the same time, I do feel like I’m only going to get one good shot. Often it’s one good shot, they’re going to make an attempt and if it doesn’t go anywhere, they’re going to kind of say, well, I guess she’s just a big girl and that’s what she’s going to be. And that’s that. So break that down for me a little bit as far as where your lines are when you’re like, no, it’s time to go to the therapeutic diet. I want to be confident when I make that recommendation to switch to a therapeutic diet and say, yes, this is the play we need to make. Where are your lines? Can you solidify that for me a little bit?

Dr. Taryn Pestalozzi (27:04):
It’s never wrong to pick a therapeutic diet for weight loss unless they have comorbidities that require other nutritional strategies. And there is not a commercially available combination diet. So there are combination joint support and weight loss diets. They’re a combination hydrolyzed and weight loss diets, et cetera. So it’s not wrong if you can find an option to do that other than it’s more expensive, I think that’s always the safe way to go. If I had a patient that did have other comorbidities, that’s the time to talk to a nutritionist or at least call the vet consult line for one of the therapeutic companies to talk to them about the case because maybe that pet really needs a homecooked diet to be able to accomplish weight loss and safely manage their other disease. But if I was going to go with a light or weight management diet over the counter, I’d be looking at patients that are maybe a six out of nine,

(28:02):
Or they have a calorie intake that’s already quite high. So if they’re eating 1.6, I’m talking about a dog right now, 1.6, 1.8 times their resting energy requirement, then I can probably reduce them at least for a while on their normal food and be safe. If they’re starting below that, which often these obese pets are, they have slow metabolisms, most of them. So if they’re starting at 1.2 or one times their resting energy requirement, then it’s not safe because I’m going to have to be cutting them back over this six to nine to 12 month process. We’re going to be making gradual reductions most likely. So we’re going to reach a point where it’s not safe for them to eat a regular diet over the counter. And I think that’s another takeaway is to talk to owners about the fact that this diet is not as short-term diet. Most of these pets have a low metabolic requirement, even once they’re at ideal body condition, so they really should be on a weight loss diet long term. I own one of these dogs, she’s on a weight loss diet for life unless I have to make a switch for another reason.

Dr. Andy Roark (29:05):
Gotcha. That makes sense. Yeah, that’s wonderful. Any other pearls I should pick up here at the very end?

Dr. Taryn Pestalozzi (29:12):
I mean, I think we’ve talked about a lot of them. It’s really about pick a starting point, monitor,

Dr. Andy Roark (29:17):
Yeah.

Dr. Taryn Pestalozzi (29:18):
Make adjustments, be a cheerleader. Those are the keys that people miss and that are what actually result in success. And I mean, we had roughly a 75 to 80% success rate and healthy weight clinic at Kansas when I was there. And most of the cases that weren’t successful, we had lack of compliance or we lost a follow-up. So I think if you work the plan so to speak, you can help a lot of these pets. And there’s like 60% of both dogs and cats that are overweight or obese currently. So this is the case you see every day.

Dr. Andy Roark (29:49):
Oh, I mean, yeah, the overweight Labrador people were like, oh, that’s really a novel case. Sandy, you haven’t seen that before. Yeah. That’s awesome. You’ve given me a number of resources. I’m going to be linking like crazy in the show notes, which I always love. People love having a list of resources. Any other that you would recommend if somebody’s just like, I love this, I love what you’re talking about. Where do you refer people who are nutrition geeks? They’re just like, yeah,

Dr. Taryn Pestalozzi (30:16):
Anymore. I’ve got a few. So the first one that will really walk you through this step-by-step is that 2014 aha weight management guidelines. There is a later like an updated version, but the 2014 as well. The meat and potatoes of this topic is the world’s model of that association has a nutrition toolkit. So that’s where you can get your body condition, your muscle condition, other resources for your support staff. Pet Nutrition Alliance does have a little online calculator you can use. I think they may have updated the website recently, so I’m not sure how they’ve changed it. And then Hill has the Bed Academy with some cece type videos about weight loss. They also have the quick reco tool that can help you initially make a plan. And then if you want more about the stats from that recent annual survey, the Association for Pet Obesity Prevention website has the results of all of the surveys, but the most recent being 2022 and they’ve got good infographics and stuff.

Dr. Andy Roark (31:12):
That’s amazing. I’ll link up to all that stuff. Dr. Taryn Peal, thank you so much for being here. I so enjoy you.

Dr. Taryn Pestalozzi (31:19):
Great, thanks. It was so nice talking about it. This was a topic that I really like.

Dr. Andy Roark (31:23):
Well, yeah, it’s obvious. That’s why I had to have you. Anyway, guys, thanks for tuning in. Everybody take care of yourselves. And that’s it, guys. That’s what I got for you. I hope you enjoyed it. I hope you got something out of it. Thanks so much to Taryn for being here. I really enjoy her. I really enjoy talking with her about weight management. It’s a thing that we talk about a lot, but man, when you find someone who is really passionate about this subject and who has had a job, just having these conversations, these are important, and just because we have ’em a lot doesn’t mean that we shouldn’t take them seriously and really think about how we get better. In fact, it’s the conversations we have a lot that we should really focus on because that’s where we can make a real difference for the clients and the pets that we see.

(32:09):
I mean, I dunno. I think a lot of times in education there’s this push to find these unique things that rarely happen and to be aware of them, and that’s okay. I really think that finding the things that happen commonly and deciding that we’re going to be amazing at them, I think that’s how we really make an impact on the world through veterinary care. Anyway, that’s just how I feel. Guys, if you have not checked at the Hill’s Veterinary Academy, you should take a look. Go and check it out. It is their learning library, it’s their Learning academy. There’s so many resources there. It is a great, great, great source of knowledge on all things nutrition. I’ll put links down in the show notes, go and check it out. Thanks to Hill’s for making this episode possible, guys. Take care of yourselves. I’ll talk to you later.

Filed Under: Podcast Tagged With: Life With Clients, Medicine

Identifying Mobility and Pain Issues on Examination (and Even Before)

October 12, 2023 by Andy Roark DVM MS

Dr. Dycus, Chief of Orthopedics at the Nexus Veterinary Bone and Joint Center and founder of Ortho Vet Consulting, shares invaluable insights into orthopedic examinations for both dogs and cats. He discusses the importance of video documentation for evaluating mobility issues, offering indispensable guidance to veterinarians and pet owners alike.

Cone Of Shame Veterinary Podcast · COS – 229 – Identifying Mobility And Pain Issues On Examination (and Even Before)

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

LINKS

Dr. David Dycus’s website

Dr. David Dycus on Instagram

Dr. David Dycus on Facebook

C.A.M. (resource for pet owners)

C.A.R.E. (resource for pet owners)

Dr. Andy Roark Resources 

Dr. Andy Roark Exam Room Communication Tool Box Team Training Course

Dr. Andy Roark Charming the Angry Client Team Training Course

Dr. Andy Roark Swag

ABOUT OUR GUEST

Dr. Dycus attended Mississippi State University’s College of Veterinary Medicine for his veterinary degree, Auburn University for a small animal rotating internship, and Mississippi State for a combined surgical residency and Masters degree.

Dr. Dycus is frequently asked to lecture locally, nationally, and internationally. He has given over 200 continuing education lectures and taught over 125 laboratories. He has published numerous research articles and authored or co-authored several book chapters. He is the co-editor of the textbook: Complications in Canine Cranial Cruciate Ligament Surgery. He was named by DVM360.com as one of the 10 veterinarians to watch in 2018. Dr. Dycus is a frequent contributor for updates in orthopedics to several veterinary websites and magazines. Dr. Dycus has also been featured on Sirius XMs Doctor Radio’s segment on Pet Health and Orthopedics. His passion for teaching has allowed Dr. Dycus to become a laboratory instructor for the CBLO, TPLO, extra-capsular stabilization, medial patella luxation, angular limb deformity, and fracture repair. He is on faculty for AO (Arbeitsgemeinschaft für Osteosynthesefragen), and he is an orthopedic consultant for VIN (Veterinary Information Network). 

Along with being a scientific reviewer for multiple journals, he serves on the editorial review board and is the associate editor (orthopedics) for Veterinary Surgery, the official publication of the American and European Colleges of Veterinary Surgeons. He has previously held an appointment on the research committee for the American College of Veterinary Surgeons. Currently Dr. Dycus is on the Board of Trustees for the American College of Veterinary Surgeons, is a council member for the Association for Veterinary Orthopedic Research and Education (AVORE), and is on the education committee for AO North America. Dr. Dycus became a certified canine rehabilitation practitioner through the University of Tennessee in 2015. He is the director and chief of orthopedic surgery at Nexus Veterinary Bone and Joint Center where he has a focus on total joint replacement, complex and minimally invasive fracture repair as well as angular limb deformity correction, 3D implant printing, and arthroscopy. In addition, he is the medical director for Nexus Veterinary Specialists located in Baltimore, Maryland. He is the founder of Ortho Vet Consulting, an educational consulting and orthopedic coaching service as well as the co-founder of the Veterinary Sports Medicine and Rehabilitation Institute (VSMRI).


EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome, everybody, to the Cone of Shame veterinary podcast. I am your host, Dr. Andy Roark. Guys, I’m here with my good friend, Dr. David Dycus. He’s an orthopedist. He lectures all over the world. He does a ton of things, which I’ll lay out here in a moment. Man, I always enjoy him. He is so useful. He’s such a wealth of knowledge and just super practical clinical knowledge. And guys, we are in the orthopedic exam today. And gosh, he just makes pearls of wisdom rain from above in this episode. It makes me so happy.
My face, I wish you could have seen my face when we get into talking about how to ask pet owners to take videos of their limping pet, and he’s like, “Yeah. This is my wishlist for how to film and what to get them to do.” And I’m like, “Man, if I was a pet owner, I would love this. I would feel empowered. I would feel like I have got some homework to do. I feel like my vet cares.” And then as the vet, I’m like, “Yeah. This is super helpful.” And it’s just a way… It’s like sometimes you struggle to ask for what you really need because you don’t exactly know how to articulate, “Hey. This is what makes a good video that’s actually going to make my life easier and not just give me more to do in my day.” And so anyway, that’s just one part of what he lays down. But man, that was probably my favorite part and we do it for dogs and cats.
At first we start off, we’re talking a lot about dogs. We very much get into cats and how cats are different and ways of diagnosing cats differently, and just, anyway, boy, the amount of knowledge packed into this episode is just absolutely over the top. So anyway, if you ever see limping animals, limping dogs or cats, this episode’s for you. 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. David Dycus. Thanks for being back on the show.

Dr. David Dycus:
Hey. Thanks for having me. It’s great like always to be back.

Dr. Andy Roark:
Oh, man. I so enjoy having you on here. You have been… I think I have you on about once a year. I should probably do more than that, but you are perennial here. I always enjoy the heck out of you. For those who don’t know you, you are a board certified veterinary surgeon. You have a sole focus in orthopedics, so you’re always in talking about limps and joints and aches and pains and corrective procedures and things like that. You are the chief of orthopedics at Nexus Veterinary Bone and Joint Center. And you also are the founder and owner of your own consulting firm, which is Ortho Vet Consulting.
So you are awesome. I love talking to you about these things. You have a passion for canine working dogs. And so it’s just something that I’ve always been interested in and it fits with your orthopedic interest. And I’ve had you on talking about osteoarthritis many times in the past and things like that. And so let’s go on. I want to just talk with you today. I’m interested in. I had just a flurry of questions recently about limping dogs and mobility. From those, do you think it’s torn? Is it partially torn? Do I need to come in? Do I need to do a surgery? Should I wait and see? And it’s just a lot of those sort of nuanced questions. And so I wanted to bring you in to kind of help me brush up a bit on identifying mobility and pain issues and just examination and then even pre-examination. Are there things I should be asking before from the pet owner? Are there things I should be looking at before I put the hands on the beast? Anything like that?
So let me just start it at a high level and sort of say when somebody comes to you and says, “Hey. Could you take a look at this limping dog?” where do you even start to process this in your mind?

Dr. David Dycus:
So I think first thing is going to be listening to the owners and gathering as much information as you can, because in a lot of situations when the dog or even the cat is in the veterinary hospital, they’re amped up. And so sometimes some of the things that the owners say are happening, you watch the dog walk, for example, and you’re like, “Well, I don’t see anything,” and you’re thinking the owner’s crazy or the dog’s getting better. So I always question them about how long it’s been going on, where they see the issues most. And I try to keep most things open-ended so I don’t persuade them one way or the other or they answer something the way I want them to.
I want them to tell me are they predominantly seeing stiffness upon rising and then the dog works out of it and looks beautiful? Or are they seeing something that the dog is stiff and then it stays consistent? Is it something that started out very intermittent and has now progressively gotten worse? Or are they actually seeing maybe some behavioral type changes? Maybe the dog’s sitting down on walks or maybe they’ve noticed that, “Usually he beats me up the stairs and hops on the bed at night, and now we’re kind of waiting on him to come up the stairs and then I’m having to bend over and help him up into the bed.” So they may notice some not necessarily limping, but they may notice some changes. And if it’s a cat, for example, perhaps they have stopped wanting to jump up onto the counter or they get up and find themselves, but then they start meowing or seeking out somebody to help them get down off of a surface because they don’t want to jump down. So I think certainly listening to the owners is a huge, huge one.

Dr. Andy Roark:
Do you have any slick sort of Jedi questions that you feel draw histories out naturally? Or do you sort of do a 20 questions like, “Hey. I’m going to ask you a bunch of questions,” and then just kind of go through a checklist in your mind? How does that sound when you’re trying to draw this out and without leading them too much?

Dr. David Dycus:
Yeah. I think sometimes when the owners come to see me, they’ve been to their regular veterinarian and they’ve maybe got an idea of what’s going on.
So they start telling me things that they think I want to hear, things they’ve looked up on the internet to try to persuade me in that direction. And so I say, “Listen. Let’s start at the very beginning.” I’ll say, “Why are we here?” “Well, my veterinarian…” and I say, “Well, no, no. What did you see at home when you first noticed something that was wrong?” And, “What changed your thought as to why you thought your dog needed to see a veterinarian?” And then they’ll say, “Well, he was limping.” “Okay. Well, how long ago was he limping?” “Well, a few months ago.” And then I say, “Okay. Well, has he just been limping the same way the whole time? Or did you notice something before?” And then they start thinking and they’re like, “Well, there was a few months ago where maybe he seemed like he slept wrong on his leg for a few days and then it went away. We didn’t think anything of it.” So that’s a huge important thing, especially when it comes to cruciate ligament disease.
Or I’ll say, “Well, are there certain times of the day where you notice the issue more?” I don’t want to say, “Are they stiff when they get up in the morning?” I just want to say, “Are there certain times of the day where you see it? Or are there certain activities that you notice the issue more more than others?” And if they’ve been on any sort of medications, say, “Well, did it help?” And they’re like, “Well, no. He’s still limping.” I’m like, “Well, did you notice any change at all for the better or just zero change?” And they’re like, “Well, maybe it helped a little bit,” because I think some of those things are very, very important.
And many a times they’ll say, “Well, I’ve got a video. Do you want to see it?” And I’m always like, “Yes. Absolutely.” And more times than not, it’s probably not even really focused on the dog and helpful, but I do think it’s important because sometimes you can see some things that the owner’s trying to describe, and I’m sitting there thinking, “What are they talking about?” They’ll say, “Well, he’s dragging his nails.” And we all think, “Oh, it’s got to be neurologic.” And I’m looking, and they’ll say, “We’ve got video.” And I’m watching the video, and it’s like, “Well, the dog doesn’t have a neurologic gait. The dog’s just too painful, so it can’t actually flex the knee or the hip enough to clear the paw and the nails are catching. And so it’s not neurologic. It’s actually orthopedic.”
So many a times, my technician will come in and she’ll be like, “Well, the owner says he’s dragging his feet.” And I’m like, “Oh. Well, this might not be orthopedic.” And so we have to be careful about the terms that we perceive in our brain that we hear without actually seeing. So I think the history is critical and then videos if they have them, and then before you even touch the animal, you have to watch them move.

Dr. Andy Roark:
Okay. Hold on. So I’m going to unpack this a little bit. Okay. Because like I said, I’ve just had a pile of these recently and, pat myself on the back, I have done a good job of saying, “Hey. Why don’t you get a video of it before you come in?” And that has been really helpful. However, David, I get it and they bring the video in and oftentimes, they’re holding the leash and they’re filming from behind or, as you said, there’s a variation in quality of the video and things like that.
Are there certain types of videos, are there shots that you’re looking for? Can I give them a little bit more coaching to get a better video? Because a lot of times, they love the idea of filming it, you know what I mean, and bring it with us so we can see what it looks like. And especially if I say, “Oh, often they’ll hide it when they come into the vet, so I really want you to get this video,” they feel like they’re hands-on, they’re part of what we’re doing, they’re on the diagnostic team. Do you give them any sort of guidance in how to get a good orthopedic video that’s going to help us look at lameness?

Dr. David Dycus:
Yeah. We try to. And for me, it’s actually, if I get the opportunity to tell them to get video before they come in, then my wishlist of videos would be someone else is walking the dog and someone is filming, so it’s not the same person walking and filming. The first thing I would like to see is the dog lying down and getting up to a walk and see what happens. That’s video one. Video two would be the dog just standing before walking. And then the next set of videos would be one video of the dog walking away from the camera, a video of the dog walking towards the camera and a video on both the left and the right side of the dog walking. And ultimately, if I can get even more videos, I would want those same series, but with the dog trotting, so the trotting towards me or the camera, trotting away from the camera, trotting a view on the left side and a view on the right side.
That would be my ultimate wishlist if I could have those videos because I think that would certainly help pinpoint a number of things. You’re able to see how does the dog look when it rises and then starts walking, how does the dog look when it’s standing. Some dogs will offload a limb at a stance, but then the minute they start walking, they’re engaging and using it, and that tells me things versus if the dog is offloading and then takes off walking and is limping. And then for some animals when they have a more mild issue, it’s easier to detect at the trot than it is the walk, because it’s a lot harder for them to hide things at the trot than it is the walk.

Dr. Andy Roark:
Hey, guys. I just want to jump in real quick and let you know about some great continuing education I have coming your way. Guys, I’ve partnered with Nationwide to put together a series of webinars that are 100% free to you. They have [inaudible 00:11:18]. They are good to go. And they are going to be, first of all, just genuinely entertaining and fascinating. The first thing I got coming for you is on October the 31st, that is on Halloween, with me. I am doing a webinar that is on a topic that I love and I care about. It’s keeping care accessible in veterinary hospitals, strategies for affordability and sustainability. This is me talking about exam room communication. It’s talking to people about money. It’s working with clients who have financial limitations. You get to hear me do my thing. I’m super excited about it. It’s at 3:00 PM Eastern, noon Pacific on October the 31st. Registration is open. I’ll put links to all of these down in the show notes.
The second one is coming up on November the 14th with my good friend, Dr. Emily Tincher. She’s been on the podcast a number of times. I love having her here. She’s such a fun, interesting person who’s a deep thinker. And so anyway, she is doing a webinar called Clinical Empathy: The Exam Room Skill that Can Transform Your Team. I’ve had Emily on the podcast before talking about clinical empathy. This is a really good skill building webinar. This is great for your support staff, as well as your doctors, but your team leads especially, but your technicians, your assistants, your CSRs, all of this, it’s such a great communication content. I think you’re going to really like it. So anyway, that is on November the 14th. It is at 3:00 PM Eastern, noon Pacific.
And then the last one in the series is on December 13th. It is with Dr. Simon Platt. It is called Head Cases: A Spectrum of Care Approach to Neurology in General Practice. So if you’re a neurology buff, if you like seizures, not like it, if you like knowing about seizures, if you like neurophysical exam, tips, tricks and hacks, things like that, this is going to be a great webinar. So again, this is on December 13th. It’s at 1:00 PM Eastern. That’s 10:00 AM Pacific Time. Gang, I would love to see you there. Links to all this stuff in the show notes. Go ahead and grab a spot. I’ll see you there. Let’s get back into this episode.
Is this the same wishlist that you have for cats? Or do you tailor your instructions? I know. It’s really hard, but that’s why. It feels to me like the videos of cats are so much more valuable, because they just… It’s so limited in what I can kind of get and use in the exam room, and so I want to do this just well. But yeah, do you tailor those? Is your wishlist still the same and you just say, “I know this could be challenging.”? How do you advise the cat owners?

Dr. David Dycus:
Yeah. So for the cat, I want the owner filming the cat just walking around, engaging its normal environment. And then if they can encourage the cat to play, so if they have a toy they can toss and the cat will go after, I want to see that. I want them to try to encourage the cat to jump up onto a surface, whether it’s a chair or a counter. And then I also want them to encourage the cat to jump off of a surface, an elevated surface, whether it’s a chair or a counter. And then even better if it’s a home that has stairs, if they can encourage the cat to either go up or down the stairs. Those things I think are very helpful, because the cat’s going to be very, very different to detect some things and especially in the hospital.
In most situations the owner has spent all morning trying to get the cat in the carrier to get to you, and then all of a sudden when they’re there in the hospital, the cat doesn’t want to come out of the carrier. And so we take them out of the carrier and I’ll put the carrier at one end of the room and I’ll put the cat at the other and I’ll watch what happens, and the cat walks with a crouched, light gait, well guess what? Every cat walks with a crouched, light gait in the hospital. So that doesn’t really help. But a limping cat’s a big deal. If you have a cat that’s you watching and that you’re like, “That cat looks like it’s limping,” that’s a big issue that needs to be dealt with. But if they can get me videos of just the cat in its normal environment, how it’s interacting, especially with stairs and jumping, that’s also going to be very helpful.

Dr. Andy Roark:
You just made my day. This is absolutely worth the cost of admission just to go through these videos with you. I freaking love this. Okay. Great. So we’ve got our videos. Let’s move into the exam room. So you said even before the examination, just try to watch the pet. And so we talked a little bit about the cat and separating from the carrier and things like that. How do you try to do this in the vet clinic? I have done everything from go just big and have people, “Let’s go outside together and we’ll go and leash it up and go,” to just trying to maneuver in the exam room or things like that. Yeah. Tell me kind of what you’re trying to accomplish before you start your exam with the patient.

Dr. David Dycus:
So I’ll start with the cat. As we said earlier, I want to watch the cat first walk and then I want to see how the cat’s going to engage in terms of jumping up and jumping down. And so what I’ll do is I’ll put the carrier on an elevated surface to see if I can encourage the cat to jump up. And then I’ll reverse rolls. I’ll put the carrier on the ground and the cat on an elevated surface to see if the cat will jump down, because jumping up or having trouble or refusing makes me start to think hind limb issues versus not wanting to jump off or hesitating. That makes me start thinking front limb issues. And for example, cats commonly suffer from elbow osteoarthritis. And so if they do jump down, they’re going to try to get their front legs unloaded as quickly as possible, so they’ll kind of slam their back legs down, so it won’t be a very nice elegant landing.
But for the dog, I really think if the dog’s coming in for limping or weakness or a mobility related issue, we really need to watch them walk in more than just the exam room, because the exam rooms usually just aren’t big enough to pick these things up. But while I’m talking to the owner, I’m going to watch what the dog’s doing. In other words, sometimes I’m staring at the dog while I’m talking to the owner and I’m looking to see if the dog’s standing, does the dog revert and start to offload a limb, or does the dog immediately go to sit down and doesn’t want to stand up, and how does their sit look or when they go to lie down, how does their lie look? And before I ever put hands on them, we’re going to watch them walk.
And so I think watching them walk towards you, watching them walk away from you, if a big enough area, watching them walk on the left and the right and then repeating the process for the trot is very important, but that means you have to have space for this. And so sometimes that can be a hallway. Sometimes it’s the outside in the parking lot. Sometimes it’s on the sidewalk. Sometimes it might be in a grassy area. I tell people, “If you’re going to remodel a hospital or if you’re going to build a hospital, architects love to design beautiful, elegant floorings, but many a times they’re not practical for our patients.” They’re slippery. And if we’ve got a neurologically or orthopedically compromised patient, there’s got to be good footing. And so if your hospital has slippery flooring, you got to move it somewhere where there’s better traction or get a bunch of yoga mats and line your hallway just for your gait evaluation so they have traction, then they’re not sliding because it makes it really challenging if the floors are slippery.

Dr. Andy Roark:
Got you. That totally makes sense. All right. So let’s start to move into our physical exam. And I’ve asked you about this before in the past, but walk through… Primary objectives in our physical examination. How do you start this out?

Dr. David Dycus:
So I think it’s dealer’s choice, and when we talk about dogs, for example, it’s dealer’s choice if you want to have them standing or lying down. I do think it creates a bit more stress in some of the animals if we try to force them in lateral recumbency for an exam. And so if I have a dog that’s relatively submissive and immediately rolls over to their back and is submitting, then I’ll just say, “Okay. Our technician will give them belly rubs and I’ll do the exam with them lying down.” But usually I want to have them standing up. And this isn’t the time where we’re going to try to perfect our wrestling skills.
The exam should be done the same way every time. For me, that means I start at the toes and I work my way up and I do the affected leg last. And so let’s say for example, it’s a right hind limb. Well, I’m going to do the left front leg first, and then I’m going to do the left hind limb, and then I’m going to do the right front leg, and then I’m going to do the right back leg. So that way if I hit an area that’s uncomfortable on the affected limb, I need to know how is this dog’s body language, because in some situations we’re not necessarily looking for pain per se. We’re sometimes looking more for tension or resistance or spasm to manipulation. And so I read a lot of body language. And so if I manipulate, say, the shoulder on the left side in a certain way, but then I manipulate the shoulder on the right side and the dog’s panting and it stops panting or kind of looks back at me or starts licking its lips, those are signs to me that the dog could be uncomfortable.
And I also rely on the feedback from my team. If my technician, say, holding the dog and she says, “Hey. This dog’s kind of pushing into me, kind of trying to get away from you,” that tells me that what I hit is likely an area of discomfort. And I’m notorious for palpating one limb that’s the affected limb last. And I don’t get a whole lot. And so I go back to the contralateral limb and I kind of dig in a little bit deeper and then I go back. And I’m notorious for going back and forth, just sometimes looking for those subtleties, especially if it just doesn’t jump out at you, “Hey. The dog’s legs dangling because it’s got a broken tibia.” Sometimes it can be tricky. And where it gets tricky is with a lot of the soft tissue injuries. That’s where it gets really challenging and where you have to hone in and look for those body language changes when you’re manipulating the animal.

Dr. Andy Roark:
Got you. All right. All that totally makes sense. Where do you see people making mistakes here, David? What sort of pitfalls do I have to look out for?

Dr. David Dycus:
I think people try to rush things. I think they try to quickly run joints through range of motion and then say, “Well, I could do it, didn’t bother the dog.” I also think sometimes our manipulations aren’t as calculated as they should be. Many a times we go just to grab the dog and then the dog tenses up. And I think the prime example there is if we’re checking for cranial drawer. What I see notoriously in notes coming in probably in the last five years is, “Well, full orthopedic exam not completed because the animal was too tense without sedation.” But unless the dog’s actively really trying to eat you, you can usually get instability if your motions are a bit more calculated. We don’t go home after work to pet our animals and we grab them in the position where we’re going to check cranial drawer. I mean, it’s super awkward position for a dog. And so if you go in with a really tight, quick grip, the dog’s going to tense down. And once they tense down, then it’s a fight of will and the dog’s going to win every time.
And so I think if you go very light touches. So for me, what I like to do is just even before I start manipulating them, I’ll run my hands down their back kind of lightly, so they’re getting that very light touch. And then I’ll run my hands down the front legs and run my hands down the back leg, just very light touch so the dog knows I’m there. And then I’ll sometimes kind of rub the medial and lateral side of the leg just very lightly before I even pick up the toe. And then if they start kind of pulling or fighting with me, I’ll let the leg go down for a minute, so I’ll give them a break, and then will re-pick up the process.
So I think if we’re focusing strictly on the orthopedic exam for an orthopedic ailment, it makes sense to slow the exam down. Now if you’re doing a quick orthopedic check, say, on a wellness exam with no complaints, you can get through it pretty quickly. I mean, probably three minutes, you can cover the entire orthopedic exam. But I do think you need to slow down. I think you need to make very calculated movements. We need to avoid quick grips. And then for example, what I find for… Again, going back to the knee, what a lot of people tend to do is when they try to check cranial drawer, they like to kind of pick the leg up, which means the hips flexed a little bit, and they try to check cranial drawer, which I find is very challenging. So actually what I’ll do is I’ll pick the leg up, I’ll extend the hip back a little bit. And that’ll release some of the tension that makes checking both cranial drawer and, for me, tibial thrust much easier.
And then when we talk about hip extension, a lot of people like to try to go to hip extension and then it’s tight and they’re like, “Oh, well, they’re resisting hip extension.” Well, if I walked up behind you and I shoved you down to touch your toes and you couldn’t bend your knees, you’re going to be like, “Ow,” and you’re going to be like, “Well, you’re tight.” Well, we kind of have to work into that. So when I go to hip extension, I’m going very slowly and I can feel that tightness and then I’m just going to push through it as we’re stretching. I’m basically doing a controlled stretch. And I find that many a times dogs when they come in, they’ve got hip pain, well, they don’t really have hip pain. It’s just they were tight and somebody tried to check their hip extension really quickly rather than kind of stretching it out.
And don’t get tunnel vision. For example, if the dog is tight with hip extension, it might not be the hip, because a dog with groin pain or a dog with tarsal pain or a dog with lower back pain or a dog with stifle pain, they’ll sometimes offload the limb and then they’re going to be compensating, which means that their hip’s going to be a bit more flexed, so they can centerline the limb a little bit, which means over time their hip’s going to get tight. And so it’s equivalent if I told you to bend over and walk bent over for weeks at a time and then stand up straight, you’re going to be really tight. So it’s the same thing. So we have to think about, “Okay. If I’m getting pain at the hock, but they’re tight on hip extension and ruling out what’s the primary issue versus the secondary issue, and the news flash is many a times in a skeletally mature dog with an acute lameness, it doesn’t matter really how bad the hips look. It’s usually not the hips that are causing the issue.

Dr. Andy Roark:
No. This is fantastic. I really, really appreciate it. David, where can people… Do you have any favorite resources that you like to refer people to?

Dr. David Dycus:
Yeah. So I’m going to give myself a shameless plug first, and then I’m going to provide other resources.

Dr. Andy Roark:
Do it.

Dr. David Dycus:
So first off would be my own website. It’s drdavid dycus.com, and my Instagram is ortho_vet and my Facebook is Dr. David Dycus. Now, resources for clients are a big deal for me, and we see many patients with osteoarthritis. And so there are two resources I’ll send clients to to learn more about how we manage osteoarthritis over the long term. One is called CAM. That’s Canine Arthritis Management. It’s a group based out of the UK. And the other is CARE, Canine Arthritis Resources and Education. And that’s based in the US. If you just Google Canine Arthritis Management or Canine Arthritis Resources and Education, you’ll probably be able to find both of those websites very easily. And that’s sort of my go-to for sending clients for OA management, so that way they can learn, “Here’s what things are going to be looking like for the rest of the dog’s life,” in a very client friendly language so they know what we’re going to be doing.

Dr. Andy Roark:
That’s fantastic. I’ll put links to all that stuff. I’ll link to David’s stuff and I’ll link to his socials and then also to the other resources as well. So I’ll put all this stuff in the show notes for you guys. David, thank you so much for being here. I always appreciate your time and insight. Gang, thanks for tuning in and listening. Take care of yourselves.

Dr. David Dycus:
Thank you. Was a pleasure.

Dr. Andy Roark:
And that’s it. Guys, that’s the episode. That’s what I got for you. Thanks to Dr. David Dycus for being here. Thanks to you guys for listening. If you found this podcast helpful, leave me an honest review wherever you get your podcast. It’s how people find the show. It means the world to me. I really do appreciate it. Anyway, guys, take care of yourselves. I’ll talk to you later on. Bye.

Filed Under: Podcast Tagged With: Life With Clients, Medicine

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