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Medicine

Please Stabilize Before You Transfer

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I’ve written before how amazing we are as veterinarians. We are 10 different specialties all wrapped into one spectacular person. When we decide what type of practice we are going to work for we may narrow down the spectrum of care we produce. GP clinics focus on vaccinations, nutrition, and common ailments that affect our pets daily. Specialty clinics focus on the complicated and sometimes unusual. Emergency clinics focus on trauma cases and true emergent situations. It’s great that we have all sorts of specialties in the veterinary world. The biggest obstacle is us working together for the good of the patient. Its not that we do it intentionally but I think a lot of clinics don’t have protocols set during times of emergency and this makes it harder for the referral clinic to treat. Here are a couple of basics to put on a checklist if you often refer emergency cases.

  1. Call the referral clinic- if you plan on sending a case please call the referral center and discuss the situation. The best route is to have the doctor call and give information to a technician or the referral doctor for a clearer line of communication. Having a receptionist call is not a good option because they cannot properly answer basic questions like, were radiographs taken or how stable is the pet. Many times we have been given the absolute wrong information because of the mechanics of the game telephone. When in doubt always relay the information directly to the referral doctor.
  2. Start an IV catheter- There aren’t many situations where this isn’t necessary but unfortunately, pets get transferred without catheterization and fluid stabilization all of the time. Think about it- hit by car– place a catheter and start fluids to reduce a shock state before transferring. Blocked cat- place a catheter and start fluids to stabilize. Bloated dog-place a catheter and start fluids. This is a critical step in stabilizing and many animals do not receive this before going to a referral center.
  3. Provide pain control- too many times patients are provided no pain control before being transferred. It is fairly easy to have a go-to chart for a quick buprenorphine or hydromorphine dose to relieve acute pain in unstable animals. Wait on any NSAIDS or steroids before a full workup can be done but a short course of an opioid can truly affect how a patient recovers.
  4. Send diagnostic results- If you plan on referring please send the results of the diagnostics you have performed. It does not help when you have taken radiographs but don’t email them to the referral clinic. It also is a big waste of the owners’ money if you perform blood work by sending it to an outside laboratory where results won’t be ready for 24 hours. If you don’t have in house labwork equipment and plan on referring that day its best to allow the referral center to perform it versus wasting time and money.
  5. Inform owners. Please make sure your owners know what they are getting themselves into. Too many times pets are transferred with no knowledge of the next steps towards recuperation. Several times I have seen blocked cat owners choose euthanasia after having to pay a second exam fee and blood work because they were not prepared for how expensive treatment can be.

You might not know a specific number but please warn owners that certain surgical cases can run a few thousand dollars (depending on the area) and it is a huge waste of the owners’ funds and time if they do not want to go forward with treatment.

We all want what is best for the pet and to do that we need to work together. Communication is key but also don’t forget your basic triage skills. You can truly make the difference if a patient lives and recovers well versus tragically succumbs to its crisis.

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

QUIZ: Which medical condition describes the kind of day you’ve had?

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This content is sponsored by Petplan. 

We’ve all had THOSE days. The ones where everything goes right. The ones where everything goes wrong. The ones where you wonder how long it would take people to notice if you just left work early and went home and ate ice cream for dinner? We totally feel you. Sit down, put your feet up, and take this quiz to figure out which acute medical diagnosis best describes the kind of day you’ve had today! And then come back tomorrow and try it again. You know…if you’re not too busy with the ice cream…
 

 

While DrAndyRoark.com has received compensation for this post from Petplan, all opinions expressed are those of the DrAndyRoark.com editorial team.

QUIZ: Which summer emergency best describes you?

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This content is sponsored by Petplan. 

The wave of back-to-school pics have hit, and you thought you were safe. HOLD IT RIGHT THERE. “Summer” might be coming to an end, but those summer emergencies aren’t going anywhere soon.

If you work in Vet Med, you know summer tends to be one of the busiest seasons of the year. Why? Because when you combine heat, outdoor activities, and water sports, you can end up with all types of trouble. So today, we’re asking an important question:

Which summer emergency best describes you?

While DrAndyRoark.com has received compensation for this post from Petplan, all opinions expressed are those of the DrAndyRoark.com editorial team.

We Need to Talk About Feline Injection Site Sarcomas

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We need to talk about Feline Injections Site Sarcomas. I will call them FISS from now on. No one really wants to talk about this subject. It makes us uncomfortable. Our whole raison d’etre as veterinarians is to prevent and treat diseases in animals. Now we have to talk about a disease we caused trying to prevent another disease? And it is horrible. Some of the vaccine companies also do not want to talk about it. I am inviting you to get a bit uncomfortable and read on. It’s important.

Thankfully, FISS is also very rare. It depends on your source, but FISS is reported in 1 in 1000 to 1 in 10,000 cats. Most veterinarians will only see a small number of these throughout their career, which is great, but we still need to talk about it.

We need to talk about vaccination protocols.

As a veterinary surgical oncologist, am I the best person to talk about vaccine recommendations in cats? No, I am not. Also, this is no longer a one protocol fits all situation. Here is what I do know, Rabies is a zoonotic disease that is fatal to animals and people. If you live anywhere that rabies is endemic, you have to vaccinate cats for rabies. Even if they stay indoors. Feline leukemia vaccine does not need to be given year after year. Most of these vaccines do not need to be given yearly. I highly recommend that you read the Feline Injection-Site Sarcoma ABCD Guidelines on Prevention and Management (Journal of Feline Medicine and Surgery 2015, 17, 606-613).

We need to talk about vaccine sites.

The recommendations to vaccinate over a limb, rather than an interscapular site, are over 20 years old. The message has gotten through – sort of. The whole idea behind vaccinating over the limb was that when FISS occurred at these sites, it could be treated by a simple amputation. This is less effective when vaccinating over the limb actually means vaccinating over the hip/flank area. This tends to happen when the cat is in a crouched position and also when you don’t actually vaccinate over the limb. If it happens, the resultant tumour in the hip/flank area will require a hemipelvectomy and body wall resection for treatment. This is not exactly what the feline vaccine associated sarcoma taskforce had in mind. You need to vaccinate below the elbow or the stifle. Really? Yes really. Every time? Yes, every time. You can do it! I did it for three years in general practise (1997-2000). You might need to bust out a towel, or a cat bag, or your best cat whispering skills, but it is worth it. While you’re at it, you can explain to the owner why you are vaccinating their cat there and let them know what to watch for in case they develop a mass in this area. What about tail vaccines? Well I am not sure, there is only one study out on this, but to be honest, this is where I vaccinate my own cat. It is a little tricky and I recommend shaving to avoid intra-fur vaccination. Also, there is a sweet spot on the tail that is high enough that you actually have a SQ to inject into, but low enough that you can easily get 5cm margins of tail if an injection site sarcoma forms there. I live in terror that this trend will catch on, but veterinarians won’t vaccinate low enough. I can’t do a cat bum-ectomy. Please don’t ask me to.

We need to talk about what causes this disease.

It is an aberrant response to chronic inflammation. There is a genetic component too, as only some cats seem to be predisposed to this and there are some reports of related cats being affected. This is hard to study because cat families don’t tend to keep in touch.

Vaccines cause inflammation. Vaccines with adjuvant cause more inflammation. That is how they work. There have been case reports of other types of injections causing FISS, including cisplatin, meloxicam and a microchip. These are one-off incidents that are even less likely than the 1 in 1000 to 1 in 10,000 cats that are getting FISS from vaccines. Some vaccine companies like to focus on the fact that other injections have been reported to cause this disease. Yes, this is true, but adjuvanted vaccines is a thing we can change and giving other injections may not be. Instead of throwing up our hands and saying, “Well any injection can cause this” let’s focus on the thing we inject into cats more than anything else – vaccines. We need to stay focused on the vaccines because they are the biggest part of this equation. We can actually decide when to vaccinate and where. This is where we can move the needle. The other side to this is that we can’t get complacent with the nonadjuvanted vaccines and start vaccinating all willy-nilly anywhere we want to because nonadjuvanted vaccines are “safe.” Stick to the distal limbs with all vaccines.

We need to talk about vaccine records.

Vaccine records are not sexy, but they are so important. The type of vaccine, lot number, expiry date and vaccine site need to be recorded. If the cat develops FISS, this needs to be reported to the vaccine company because it is an adverse event. This is a highly aggressive fibrosarcoma. It really doesn’t get any more adverse than that. As an added bonus, when you have all of this information, a lot of vaccine companies can be really great about helping the owner to treat this disease. I mean dollars in their pockets to help with the cost of diagnostics and sometimes even therapy. I have had vaccine companies give between $1,000 to $4,000 to my clients to help with treatment. Please report these to the vaccine companies. And, hey, giving these companies all of the information about a FISS that occurred with their vaccine might help them to understand what is going on better. Science!

We need to talk about what to do when you see a mass at an injection site.

Hopefully you have an educated client who will come back if a mass develops at a vaccine site. Hopefully the mass is small and located below the elbow or the stifle. Hopefully you will recognize this may be an injection site sarcoma. Most of the time, a fine needle aspirate is a great test to do on a new mass. However, in the case of FISS, cytology is not your friend. It might lead you to believe that this is just inflammation. You can do an FNA to rule out other tumour types if you want, but ultimately, you are going to need histopathology. An incisional biopsy should be performed on masses that have been present for more than a month after vaccination. The goal is to get a small amount of tissue and to leave the mass intact so that it can be removed with wide or radical margins if it is a FISS. Excisional biopsies are problematic because they can make definitive resection much more difficult and, let’s face it, this is already difficult.

We need to talk about how we are removing these.

Current recommendations are 5cm radial margins and two fascial planes deep. If you think about the smallest FISS we diagnose, it is around 2cm. If you take 5cm margins, that is a 12cm diameter defect – in a cat. It is usually successful if you are lucky enough to get an early diagnosis and a location that is amenable to a radical surgery. These are two things that we have control over by educating the client, doing an excellent work up and placing the vaccine in a location where we can get 5cm margins.

I used to enjoy of the challenge of a big FISS surgery. Now I just feel sad when I treat these cases and I need to do a hemipelvectomy and/or body wall resection. This is because I know that if the vaccine had been placed low on the limb, I could have achieved the same or actually much better with a simple limb amputation. These cats are breaking my heart. I honestly can’t do any more lectures on huge cat-ectomies for this terrible disease. I can’t do another panel discussion at a conference arguing the finer points of whether we should do radiation before we remove a huge portion of cat or after we remove a huge portion of cat. It is ridiculous. The answer is we shouldn’t be doing either of these things. We need to do better as a profession and do whatever we can to decrease the incidence of disease, diagnose it earlier, and make it easier to treat. Please let’s work together on this. I know it is only 1 in 1,000 to 1 in 10,000 cats, but to cat owners going through this, this cat is one in a million.

Thanks for the talk.
#NoCatLeftBehind

[columns]
[column width=”one-half”]Things We Can Change
Don’t over vaccinate. Create protocols that are appropriate for the level of risk
Consider using non-adjuvanted vaccines
Vaccinate below the stifle and elbow
Focus on gentle handling of cats to allow you to vaccinate low on limbs
Record every vaccination and site in your medical records
Educate clients on what to look for and what to do if a mass develops
If you see a mass at an injection site, do an incisional biopsy without delay
Report FISS as an adverse event
Wide or radical excision as the first, curative surgery

[/column]
[column width=”one-half”]

Things We Can’t Change
Some cats are predisposed to developing FISS at sites of chronic inflammation
FISS is an extremely aggressive tumor that requires aggressive resection
Cats need to be vaccinated for rabies
Some cats do not care for the veterinary clinic/vaccine experience

[/column]
[/columns]

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

Anesthetic Deaths Happen to Anesthesia Experts, Too

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As an anesthesia technician, one of the things we are told early on is that if you don’t have a death under anesthesia “you aren’t doing enough anesthesia.” This can be a hard fact to stomach, but it’s true. If like me, you’re performing anesthesia for 80 percent of your day at work you see death from many causes whether it be drug related or caused by a disease process unable to compensate for the changes in physiology caused by anesthesia. A 2012 study showed that an overall death rate for animals undergoing anesthesia was 1.35 percent.

So, what do you do when you and your patient fall into that 1.35 percent? How do you as a team leader guide your staff through the tragedy and all of the feelings associated? How do you pick up the pieces and move on to other surgeries and other patients that need your expertise? And how do you do all of these things when the patient belongs to one of your own team members?

About three weeks ago that’s exactly what was swirling around in my head as I tried to comprehend what was unfolding.

I have been in the anesthesia field for 14 years and I have to say it’s my love, it’s my comfortable bed in the clinic. I know the beep and hum of my monitors and am soothed by the swishing of a doppler. I have a respect for death because in anesthesia he is always waiting in the corner. But as I have become more proficient with this field, he has shrunk down. Over time, he has even started to blend in with the walls.

When this tragedy struck our hospital, I had all of the same questions I usually do as a supervisor: How? Why? When? Where? Trying to piece together details to come to an informed decision and explain how this could have happened. But the different thing was: this wasn’t another employee I was trying to rationalize with and talk down before they leave vet med completely forever… this time I was talking to myself. I was the technician in charge of this pet and I had failed.

I had missed something, I was incapable of fixing this problem. As other employees rallied around me I noticed how supportive they were. They could have easily come around with blame and anger and gossip but instead it was love. I received the most profound statement from my hospital administrator, a simple text message that read:

“I am so sorry you are going through this tragedy. We will process this together, we will heal together, and if a change needs to be made, we will do it together.”

If only all practice cultures could get on board with this! We are a team, we will do this together, we will have fun together, we will go through tragedy, and we will be a better team because we will do it together.

I still have so much self-doubt and guilt when it comes to this situation. I wish I could have done more. For a minute I questioned whether or not I should continue in vet med. But, I am an anesthesia technician. Death and I can share the same space. I just hope he doesn’t think I will leave my love when I become part of the 1.35 percent.

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

Why You Should Consider “Drastic” Measures for Your Pet’s Cancer

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I hate osteosarcoma. This bone cancer is a cause of major pain for pets and heartbreak for their owners. Many dogs with osteosarcoma have a greatly improved prognosis with limb amputation.

However, the word “amputation” sends owners into a tailspin, and for good reason. They either have personal experience or they watch TV shows and movies where humans have amputation performed. Then they watch the amputee suffering through the mental and physical trauma as they adjust to missing a limb.

No one wants that for their beloved pet. What they don’t realize is that animals adjust rapidly in most cases. The pain they experienced in the cancerous limb is much worse than the healing pain of the amputation. My biggest problem with leg amputation is trying to keep my patients from running around while it heals!

In some cases, amputation is curative. Please, please read that again. Cancer can be CURED with amputation of a limb. Death can be warded off for months or even years in cases where a cure isn’t possible. Most importantly, quality of life can be restored to an acceptable level once the offending part is removed.

There are some cases where an amputation may not be the best choice. Pets whose cancer has spread can benefit from removal of the pain, but the cost of the procedure in relation to time left with good quality of life must be considered. If a pet has severe arthritis in their other limbs, removing one puts more pressure on the others.

However, with joint supplements and proper pain control, this may still be an option. I am still surprised and sad to see so many pets at the end of their lives that have never had any pain relief at all for their arthritis, but I digress.

When I worked in the shelter, I performed a large number of amputations. We didn’t have the funds to have fracture repairs done on pets. Amputation of a fractured limb was our only option. Animals with eye trauma or disease had eye removal (enucleation) performed. I vividly remember one of my enucleation cats rubbing her eye stitches against my hand while purring just a few hours after surgery!

If amputation isn’t an option for you, I completely respect your choice. I just want to make sure you are making a well-informed choice instead of having a knee-jerk response to the word “amputation”.

I’d hate for you and your pet to miss out on quality time together. If you have fears about the procedure, ask your veterinarian or veterinary nurse about their experiences (odds are, they’ve not only created tripods, they’ve owned them!).

This was my tripod, Jambie. He was injured badly as a kitten, and I amputated his leg. I was a young vet and terrified to perform the procedure, especially on such a small patient. He did extremely well. Sadly, I only had him for 3 years before a urinary problem from the trauma of the accident took him from me.

Still, I’m happy we got to love each other for 3 years and am grateful my boss was generous enough to allow me to operate on him. I took him home with me the night of his surgery to watch and worry over him, and he never left!  If you have a tripod (or tripawd), please share their story so we can save more lives and get more time with our pets because of this procedure. Don’t let fear steal your pet early!

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.