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Medicine

5 Questions You Need to Answer Before Anesthetic Procedures

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Oftentimes our clients are faced with the decision whether or not to put their pets under general anesthesia for a surgical or dental procedure. Patients do not get the care they need when pet parents are scared of anesthesia.

During this time, they look to us, the knowledgeable veterinary staff, for answers. With so many advances in the field of veterinary anesthesia there are many reasons why anesthetic procedures are safer than ever!

Here are the 5 questions you should be able to answer before a pet undergoes an anesthetic procedure.

1. What pre-op testing is required?

Often pre-op blood work can give you early clues to potential diseases such as diabetes and hyperthyroidism. Also it is important to check the function of both the liver and the kidneys since they are the organs responsible for processing and clearing anesthetic drugs from the body.

If the pet is a senior more in depth pre-op diagnostics such as and ECG or cardiac ultrasound should be considered to ensure the patient’s heart is healthy enough for some anesthetic drugs. Getting a clear picture before anesthesia can ensure that the most appropriate drugs are used.

2.Who will be monitoring the patient?

Today’s technology allows people to do more tasks at the same time, and there is a strong myth that we can “multitask”. A 2008 study at the University of Michigan showed that we don’t do lots of things simultaneously. Instead, we switch our attention from task to task extremely quickly.

As the technician in charge of a case, I want to focus solely on the anesthetic event. So, it helps that many veterinary practices now have a technician whose sole job is to monitor the pet under anesthesia. This is very important because with a dedicated technician anesthetist, the doctor can focus solely on the surgical or dental procedure being performed.

3.What monitors will be used during the anesthetic event?

During anesthesia it is important to monitor changes in temperature, blood pressure, and ventilation. These changes can influence not only what drugs will be used in the post-operative period, but will help guide the quality of recovery for your patient.

In the age of Dr. Google and information symmetry, your clients know what’s available.  Be prepared to have a conversation with the client to explain why properly monitoring blood pressure in those senior pets is so important!

4.What should the pet parents expect during recovery?

Some surgeries will only require a short recovery time.  Orthopedic and dentistry procedures that have required multiple extractions may require a longer recovery time. After surgery patients may be unsteady on their feet and unable to walk up or down stairs.

If the pet usually sleeps upstairs in the owners’ bed, it’s important to set up a comfortable area on the first floor for the patient to rest in when they come home, or be prepared to carry that patient up and down the stairs! And be realistic with expectations.

5. What will the pain management plan be?

Almost every surgical and dental procedure will involve some level of pain. Be ready to talk with the clients about the expected level of pain and how this pain will be treated. Talk about the need for post-operative physical therapy.

Orthopedic procedures greatly benefit from post-operative physical therapy such as hydrotherapy, massage therapy, and low level laser therapy. Many pain medications have to be administered orally. If it is difficult to give those patients a pill, work on other options to ensure the pet stays comfortable in the recovery period.

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.

Are You Haunted By Negative Exploratories?

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A few years ago, I wrote an article entitled “No such thing as a negative exploratory.”* Shortly thereafter, I received an amazing email from a colleague on the other side of the world.

Dr. Andreane Daigle, who practices in Queensland, Australia, shared with me a story about an exploratory laparotomy she performed on a vomiting nine-year-old dog after x-rays revealed a possible foreign body. When she went in, however, she found nothing.

“Ohhhh, how disappointed and angry at myself was I, when all I found was an erythemic small intestine,” she wrote. “The client now has a bill of about 2K because of my lack of confidence… If I would have just waited another day, maybe none of that would have happened… So I was hoping you could guide me with your experience. What questions do you ask yourself? How do you decide to go to surgery?”

Wow, what an incredible email!

My reply was:

Hi Andreane,

I think that what you did is fine. This has nothing to do with confidence.

However, it has to do with the art of veterinary medicine, rather than pure science.

Sitting on a suspected FB can be a recipe for disaster, so I can’t possibly recommend it. On Monday, the intestine may be fine, and an enterotomy may be enough. On Tuesday, the intestine may be so angry that an R & A is necessary. And on Wednesday, the dog may perforate and end up with septic peritonitis!

So earlier intervention is usually preferred… but not always. I have a hard time believing that waiting another day would have changed much to the health of the intestine… but your biopsy will confirm that.”

A week later, the biopsy results confirmed that this 9-year-old jack Russell had IBD.

Young Andreane had made the right decision after all.

Still, as I wrote in the original article*, there should be no such thing as a negative exploratory. If you don’t find anything grossly abnormal or fixable or removable, then you should at least take multiple biopsies and submit them to the lab.

Of course, saying “you should” is a diplomatically correct way to say that you must…

At a minimum, biopsies should include the stomach, the duodenum, the jejunum (maybe 2 levels), and very importantly the ileum, often forgotten but a common site for IBD. Depending on the specific situation, you may also need biopsies of the liver, pancreas, mesenteric lymph nodes etc.

You may have heard this saying: “If you don’t have negative exploratory laparotomies, you’re not doing enough of them.” In other words, a negative exploratory laparotomy is perfectly acceptable. I respectfully disagree with this philosophy. A laparotomy can be negative if you throw your hands up in the air, cuss a few times, and close the patient on the spot. But it will not be a negative exploratory until you take and submit a bunch of biopsies.

When should we consider an exploratory laparotomy? By definition, when we are not 100 % convinced about the diagnosis. Arguably, this could be when a patient presents with:

  • Unexplained and unresolved hematemesis or melena.
  • Chronic weight loss of unknown origin.
  • A history of eating foreign bodies, especially in puppies and kittens
  • A history of eating foreign bodies, especially in older patients – a classic suggestion for IBD.
  • A questionable barium study.
  • A penetrating injury to the abdomen, such as a gunshot wound.
    Unexplained and unresolved gastric or intestinal distension with no radiographic or ultrasonographic evidence of obstruction.
  • A focal intestinal lesion seen on ultrasound, such as a mass or disrupted layers.
  • An increase in bilirubin without a logical explanation.
  • When partial thickness GI biopsies taken via endoscopy do not provide answers that may be provided by full thickness GI biopsies performed surgically. Studies show that surgical biopsies are more reliable than endoscopic samples because of the difference in depth.

If you are still in doubt based on the history, the physical exam, blood work and X-rays, ultrasound is a great, non-invasive modality to guide you. The secret: ultrasound should be performed and read by well-trained individuals.

What are the consequences of “closing” a patient after a negative exploratory without taking (and submitting) biopsies?

Here are at least 4 consequences:
1. We (still) cannot document whether or not there is GI or some other abdominal disease.
2. The patient, who may (still) be debilitated, may need to have another anesthetic episode to have endoscopic or surgical biopsies harvested.
3. You may need to admit to a disgruntled internist (or surgeon) that you didn’t take biopsies!
4. And you need to have the same tricky discussion with an unhappy client.

Over a year later, I asked Andreane for permission to use her name for this story. In her approval email, she wrote:

“Interesting timing, I was talking about you to my colleague 2 days ago. I had a cat with GI signs and I wanted to do a laparotomy. He was telling me to wait… but I thought of you and went in yesterday… I found an obstruction due to chicken necks.”

Way to go Andreane!

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.

* “No Such Thing As a Negative Exploratory”. Veterinary Practice News. Published March 2nd, 2010.

Why Veterinary Professionals Are Medical Professionals Too

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Recently I was part of an argument in a comments section on Facebook. I told myself not to get involved but after seeing so many veterinary technicians and veterinarians beaming with pride regarding our profession I couldn’t sit back and not defend my colleagues.

The medical community is vast- Human physicians, dentists, psychologists, pharmacists, nurses, biologists… and veterinarians, and veterinary technicians.  We fit in there too. But unfortunately, there are a lot of medical professionals that view us as less than because we work on animals and not humans. Our degrees aren’t equal for these people. They get upset when we try to equate the same tasks and jobs that veterinarians do to human physicians. Instead of understanding our job, they continue to ignore the parallels.  This creates a lot of issues in the medical community and makes veterinarians and technicians feel like second-class citizens.

In undergrad, I was tracking “Pre-Med.” I had a lot of classmates that were considering different careers- a few dentists, a pharmacist, and a few medical doctors.  Unfortunately, a few of those classmates made fun of my choice to apply for veterinary school. I got a lot of “you won’t even be a real doctor” and “that will be an easy job.” Even in undergrad, the misconceptions of what being a veterinarian was all about were vast.

Fast-forward to today where I still have to defend my choice and defend my veterinary technicians.  I am not trying to covet anyone’s job. I am not trying to make it seem like human physicians do not work hard. I am trying to show people how alike our fields are and that everyone deserves respect.  I am not going to get into the argument if veterinary technicians should be called nurses- in certain countries they are but in the U.S they are technicians. That isn’t what this article is about. What I do what to discuss is how alike our professions are without creating more animosity towards each other.

A veterinarian goes through 4 years of pre-med undergraduate school and then another 4 years of veterinary school. Every course that we take is exactly the same as our human counterparts but geared towards animals. Unfortunately instead of learning these courses for one species veterinarians have to learn it for all species. I wish I could say that a cat is similar to a small dog but I think all of my former professors would be fuming.

During our fourth year, we go through rotations that focus on surgery, internal medicine, oncology, etc. We prepare and study for the national board exam and then usually have to take a state board exam to get licensed.

As veterinarians, we are expected to be able to handle a variety of medical specialties in the course of a regular day. I can go from a puppy exam discussing early life nutrition, vaccinations, and care to an oncology appointment where I am discussing what types of chemotherapy might be best for lymphoma.  During that, I may get an emergency surgery presented where I have to stabilize the patient and prepare the owners for complications and issues with undergoing anesthesia.

We see similar metabolic diseases as our human counterparts and run the exact same types of tests to monitor and track these diseases. Just because we work on animals doesn’t make our jobs any less important and any less different than human physicians.

A veterinary technician goes through a similar path. They go through schooling learning microbiology and other similar courses as nurses do. Although they obtain an associate’s degree their job parallels the work of human nurses. A veterinary technician is the one who is your pet’s advocate. They place IV catheters in hissing cats and then have to read fecal samples, blood smears, and skin scrapes.

Veterinary technicians are the ones monitoring your patient under anesthetic and have a vast amount of knowledge in anesthesia, radiology, and internal medicine. They are crucial to the veterinary field, just like nurses, and deserve to be acknowledged for their skills.

Maybe you don’t value an animal’s life and thus don’t value the work that a veterinarian and their technicians accomplish daily. Maybe even after explaining how our training is exactly alike you still don’t think that the professions are the same.  What I suggest is to walk a day or a week or a month in the shoes of a veterinarian and a technician. Ask if you can shadow a busy veterinary hospital and see for yourself.  Don’t ignore another profession because you don’t understand it.

The world is full of misunderstandings and hatred because we choose to stay in our bubble and not experience others’ experiences. I love my human counterparts and nurses – I know how hard they work and the daily tasks they have to endure. I hope eventually we receive that same respect.

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.

How My ER Visits Made Me a Better Vet

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In this article we are going to get a little bit personal. Not telling you the color of my underwear personal, but close. In the past month or so I have had two run-ins with the hospital (human hospitals.)

One was a scheduled elbow replacement that just took place, the other was a very unscheduled hip dislocation about a month before. The hip dislocation took me to the emergency department, while the replacement took place through a scheduled operating room intake. Don’t worry, we are past the time when you need to send me bouquets (fruit baskets accepted year round, though.)

Both of these got me thinking about the differences between human medicine and animal medicine and made me consider how I could take the positives and negatives from my experiences and make my clinic a better place for patients.

For better and worse, the two fields are very different. I have nothing but respect for human nurses, PAs, LNAs, PAs, MDs and the rest of the field. Both of my hospital experiences weren’t especially new to me, but now that I have been out in the field longer I try to look at things from the perspective of my own clinic and patients. I also tend to stay away from the ER, so this was only my second visit there ever. I look on the bright side of these hospital visits and become a better vet because of them.

The first thing that happened when I arrived at the emergency room was that I was asked what was wrong. I knew that I had dislocated my hip because I heard it, felt it and could easily evaluate that it was in the wrong place.

Our animals don’t have this advantage which is why fast, gentle and complete physical exams should always be the first thing that we do. The second thing to do in many situations is pain medication. The speed with which I get pain medication to my patients is light years faster than often happens in the human field. I want every patient that enters my clinic in pain to have the benefit of a very fast resolution. Their pain is hidden better than ours, but directly related to their fear.

I tried to imagine how I would feel if I didn’t know what had happened and couldn’t speak the same language as my nurses and doctors. I was able to reason out what was happening, but if I took only my pain and eliminated the ability to think about a plan for the future I can only imagine how scared I would have been. This is the angle that my patients are coming at me from, and it must always be the forefront of our minds as veterinarians.

Veterinary medicine is much more hands on than human medicine- and let’s be honest, you would rather put your hands on fur than a human as well. Other than vitals, often we go entire visits without our doctors touching us. We typically see physicians for each specialized field, while your veterinarian encompasses all of those fields. My orthopedic surgeon has never felt my spleen, while hardly any pet goes through my clinic without a complete abdominal exam. My surgeon can also rebuild and replace bones in a way that I could not.

It is often said that specialists have knowledge which is one inch wide and one mile deep, while general practitioners have knowledge one mile wide and one inch deep. In human medicine, each field is very specialized. Your veterinarian likely has a wider breadth of knowledge, but must refer you elsewhere for very specific problems.

Now let’s talk about hospitalization. At my ER visit I was in the hospital wearing the clothes I was going to ride my horse in. Once I got fixed up it was 1:30 am. All I wanted were PJs and to take my contacts out. I can guess that when our dogs wake up from surgery all they want is their favorite toy and a soft bed.

When I needed something, I could just hit a call button. I could tell my nurses exactly what I wanted. I could tell them my pain score, if the medicine was working, how well it was working and what needed to change. These are all things we need to try and predict for our patients since they don’t have the benefit of a call button.

Did you know that we monitor all of these things in pets too? We don’t have questions to ask them, but we watch parameters like heart rate, position in the cage, ear position, pupil appearance and breathing to monitor pain.  We use the results of studies to create a generalized approach in our patients, then monitor them as individuals. We make sure that pets haven’t rolled over on a surgical area and have soft beds. We get the benefit of our patients not talking back with the downside of them not being able to tell us how they feel.

A couple of months ago while I was at a vet meeting my husband called because my dog had peed on the floor. She is very well trained and not prone to that type of thing. I questioned if she asked to go out and he said she hadn’t made a peep. I clarified that if she walks to the far end of the living room and back twice with her ears in a certain position it means she wants to go out. He justifiably told me I was crazy.

The fact is that we get very attuned to nonverbal communication from our pets. I never want crying in pain to be my first indicator that I need to intervene on behalf of a patient. It is important that I look for other silent signs to help them before they are in a high degree of pain.

Now that I am on the mend I have the benefit of stepping back and looking at the positives and negatives from my visits. While they made me less able to do intense physical labor for a while, I am hoping that they also improved my skills as a veterinarian. While I am always attuned to my patients’ needs and wants while they are in my clinic, it is helpful (though not actually very fun) to view it from the other angle.

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.

image1 (1)Dr. Anna Dunton-Gallagher is a 2011 graduate of Ross University School of Veterinary Medicine. She completed her clinical year at the Virginia Maryland Regional School of Veterinary Medicine and then settled back into her hometown of Rutland, VT to practice. She loves wellness pet care, pain management and her clients. When not at work she enjoys spending time with her pets, snowboarding and horseback riding..