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Medicine

CBD, Labor Shortage, and Non-Economic Damages with Mark Cushing

November 9, 2022 by Andy Roark DVM MS

Mark Cushing Joins Dr. Andy Roark to review recent trends and policy battles in veterinary medicine. He discusses the veterinary labor shortage, telemedicine, nurse practitioners, lawsuit damages and CBD regulation. He also gives his predictions for the midterm 2022 elections and how they will impact veterinary medicine in the coming year.

Cone Of Shame Veterinary Podcast · COS – 169 – CBD, Labor Shortage, And Non – Economic Damages With Mark Cushing

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

LINKS

Practice Owner Summit: https://unchartedvet.com/practice-owner-summit-2022/

Pet Nation: https://amzn.to/3yNT8gj

Animal Policy Group: https://animalpolicygroup.com/

Mark Cushing Website: https://www.marklcushing.com/

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/on-demand-staff-training/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Mark is the Founder and Managing Partner of the Animal Policy Group, LLC, based in Scottsdale, AZ, Portland, OR, and Los Angeles. APG’s clients represent a wide-range of pet health, animal welfare and veterinary educational interests. Mark focuses his practice on providing high-level strategic advice, government advocacy, regulatory and policy services to animal health and veterinary clients with needs at any level of government, and universities and industry groups throughout North America. Mark is a frequent speaker at veterinary medicine and other animal policy conferences. He is a former partner of major regional and national law firms and served as an adjunct professor of law at the LMU Duncan School of Law in Knoxville, Lewis & Clark Law School in Portland, and the University of Oregon School of Law. He is an Honors graduate with distinction from Stanford University and the Willamette University College of Law. Most recently, Mark is the author of Pet Nation, a book released by Penguin Random House that illustrates an inside look at the forces behind how our pets transformed American society and culture.


EPISODE TRANSCRIPT

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

Dr. Andy Roark:
Welcome, everybody, to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I’m here today with the one and only, Mark Cushing. If you haven’t heard Mark before, you’re in for a treat. He’s very opinionated. He has got his fingers in a lot of pies. He knows a lot about how our industry works. And I’m just thrilled to have him here. Gang, we talk about everything from the vet med labor shortage, to nurse practitioners and telemedicine, to noneconomic damages and lawsuits too. And we focus on this [inaudible 00:00:41] CBD oil and CBD regulations. Gang, it is today a sprawling, sprawling conversation. We even talk some politics, we talk midterm elections and inflation and what that means or could mean for vet medicine in the coming year. It’s a really fun one. Gang, I hope you’ll enjoy it. Let’s get into this episode.

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

Dr. Andy Roark:
Welcome to the podcast, Mark Cushing. Thanks for being here.

Mark Cushing:
Great to join us as always, Andy. Hope you’re well.

Dr. Andy Roark:
I am. So I love having you here. For those who don’t know you, Mark Cushing is a lawyer. He is a founder and CEO of the Animal Policy Group. And he is the author of the book Pet Nation. I’ve had you on the podcast before. We’ve talked about the book. We’ve talked about a lot of things. You always come to my mind this time of year because I used to get to see you at the Banfield Industry Summit, which is a great event. But you are generally invited to share your perspective on the industry and where it’s going. And what are the hot topics in the coming year? And I love that, I love hearing you speak about that. You just always give me a ton of ideas.
And I just wanted to have you on the podcast today and kind of run … I think I’d like to sort of hear an overview because I didn’t get to hear you at Banfield this year. What are the hot topics you see coming down the pipes for the industry? And then one area that I know that you’re involved is in the legality of CBD. That was a topic that got really hot, and then it kind of seemed to cool down. And I’m sensing it’s warming back up and I’m seeing a lot more about it again. I wanted to talk to you about that. Does that sound okay?

Mark Cushing:
Let’s go. I’ll jump in on the first.

Dr. Andy Roark:
Yeah, take it from there.

Mark Cushing:
And Banfield punished the attendees by making them sit through breakfast to hear my overview. So I go about 180 miles an hour because I try to cover all the legislation the past year. We started out my group by looking at 25,000 bills and reduced it down to about 350. The point being, when you’re successful and financially, the industry as you know, 2020, 2021, now 2022 are each the greatest years financially than the year before ever, so that puts a bullseye on your back, and I kind of reminded the industry leaders that, that attracts attention. And it often attracts legislation of people wanting to help you, I.E, get a piece of your action, so to speak.
And what were some interesting trends this year? Industry wide, the conversation right now is dominated by the veterinary shortage and the vet tech shortage, period. And there has been reluctance, I think foolish on the part of some trade associations to acknowledge it because all you have to do is talk to a practicing veterinarian anywhere in the country, rural, suburban, urban, East, West, North, South, doesn’t matter. They’re in an acute shortage scenario. And the law of economics, as you know, Andy, means if you have a shortage of something, a shortage of supply of veterinarians, fewer people get care and the price of care goes up. Neither one of those are trends that people feel comfortable with.
I’m not trained enough to talk about the impact and the burnout on veterinary staffs, which is obvious. But we have this millennial and gen Z pet owner group, the largest cohorts of pet owners now in the country, they want to spend money on vet care, they want to treat their pets’ healthcare at the same scale that they take care of their own healthcare. And money really isn’t an issue, which is, quote, a great problem to have, but you’ve got to have enough caregivers to do that. And they’re frustrated. And the headwind we’re heading into will be people that were going to get a second dog, or a cat, or a second cat, or a third because they want playmates and they enjoy the first ones they have so much. But if you can’t get in to see a vet, I can see the conversation between a couple being, “Honey, why are we thinking about a second dog when we can’t get Sparky in to see our veterinarian for a month?” So that’s a tough issue, and it surfaces in different directions.
One is, and you know I’m an advocate for telemedicine. I wrote the first article for the industry back in 2015. I didn’t create telemedicine, I just watched what it’s done in human medicines. It’s legal in all 50 states and it’s now important. It’s a fundamental way people get care if they can’t get in to see a doc. And telemedicine is on the table now in a different context than just it’s convenient and I don’t want to leave my house, or I don’t want to go to a clinic. It’s I can’t get into a clinic. So the arguments against telemedicine become more and more theoretical and less and less real. Number one, number two, it’s opened the door for people to say, “Yeah, human medicine’s had PAs and nurse practitioners for 60 years.” Let me tell you what 60 years means. That means there’s grandparents, kids, and grandkids that have been PAs in this country. We have them all through the US. And again, we would have enormous medical deserts absent nurse practitioners and PAs.
So we’ve had 60 years to learn from it. Obviously, I’m a fan of that. Lincoln Memorial’s opened its first master’s program to create that. And that thinking’s changed. We find people saying, “We certainly shouldn’t fear competition from PAs. Good Lord, we don’t have enough vets as is.” And it would free veterinarians up to do more things, higher value things. So that conversation’s changed. You now see more states, they’re blue states, they’re mainly in the Northeast and Mid-Atlantic, look at noneconomic damages and saying, “We see all this literature where veterinarians say, ‘We treat your pets as family,'” which is true. They have that. They have a unique role in our lives that’s more like kids, and that is like certainly a chair or a skateboard. So why don’t we get the damage awards to include emotional damages, loss of companionship, that human medicine gets? And that’s a tough issue.
I’m still a strong critic of that idea, and my clients are. Why? Because all that does is drive up the cost of vet care, and therefore reduces access. Why is that? Because we pay 750 bucks for liability insurance, vets do now, versus 200,000 that an OB/GYN pays. And if you think that number doesn’t show up in new technology, defensive medicine, and rising costs, which shrinks access, so it’s an interesting debate. But that’s got some tailwind behind it, and we’ll see more and more states want to push that.

Dr. Andy Roark:
Yeah. And let me ask you about that because you’re actually the perfect person to ask this about. I think a lot about this, and whenever I hear noneconomic damages, I’ll be honest, I feel the muscles in my face tighten. You know what I mean? I feel the stress in my forehead come in because just to me, that seems catastrophic, I mean really. And I want you to talk me down here.

Mark Cushing:
It is.

Dr. Andy Roark:
Give me some … Don’t say, “It is.” I wanted you to say, “No, Andy. It’s bad, but it’s not awful.” But it just seems to me, I go, “Look, we’re trying to do everything that we can to provide access,” but when people start suing for six, seven figures when something goes wrong with their pet, suddenly we go, “No, I’m not doing this without an ultrasound, or I’m not doing this without a CT scan.” And I don’t see how that doesn’t just rocket the cost of care multiple times above what it is now. Am I wrong? Are there shades of gray that I’m not seeing here?

Mark Cushing:
You’re not wrong. The truth is, all lawsuits against doctors, the plaintiff’s lawyers that take those cases have them on contingent fees. You see the ads, the billboards in every highway in America. Doesn’t cost you anything. Mark Cushing, come see me, in a car accident, won’t cost you anything. It’s true. You don’t have an out of pocket cost. But they get a third of it. There aren’t lawsuits against veterinarians now with any scale or volume for a simple reason. Lawyers don’t get out of bed for one third of $2000.

Dr. Andy Roark:
Right.

Mark Cushing:
You don’t spend two years pursuing a case that you might make 600 bucks. So when you change that, two things happen. The number of lawsuit, when people recover … Your Shih Tzu dies at age 12, and they claim that the doctor negligently performed surgery, when the gates are open on whatever a jury things would emotionally reward you or compensate you for that loss, two things happen. Lawsuits get filed. Plaintiff’s lawyers get organized. TV ads start appearing of the sort, they ask if you’re in a certain group, asbestos, you’re in a certain group for something else. Now it’s: Are you a pet [inaudible 00:09:56] a pet in America? Have you lost a pet in your life? Really emotionally compelling ads.
The second thing that happens that’s even more troublesome is the insurance underwriters, if one state does that, they step back and go, “Wait a second. Our job’s to manage risk here. The risk just went up by X amount,” so now across the country, they start raising premiums to get ready for it. And then you bake that in, if you’re a veterinarian and you’re cost of doing business increases by $50,000 in the year, you don’t think you find a way to try to recover that. And so the rich can afford it, but we’ve never had healthcare for pets, nor have we had pet ownership be one that’s dependent on income, period.
I did a study nationally in 2015. People that made less than $30,000 a year owned dogs at the same percentage level as people that made over $100,000. And that goes away in this scenario. So there’s nothing good about it, and you might say, “Well, it compensates Mrs. Brown that loved that dog, and she got a nice check for a million five.” Well, actually, she got a million because her lawyers got $500,000. But is that worth it as a social policy? That’s why on the human side, you can’t make a claim for your brother, your sister, your favorite aunt or uncle, your favorite grandparent, your best friend, your girlfriend. It’s limited to your spouse or a child. And so the argument tries to shoehorn pets into being a child. My view is, and I’ve said it publicly, I’ve appeared in front of legislatures and debates all the time, I say pets aren’t children. Pets are a different species. In fact, of course they’re a different species. They’re dog and cat or some other pet.
But they’re also, they have a different relationship. In many cases, they’re nicer than kids. I have five kids. And the point is, you can’t simply say they are kids. They’re not. They’re something different. They live a short life, sadly. We’d all love our favorite dog to live to 60. Not the case, obviously, you know as a doctor. So that analogy, and we’ve won for all 16 years I’ve been involved in the industry. But the waves are bigger coming at us right now, and I don’t think it’s going to go away. So that’s bed news, I’m sorry to start your program off with [inaudible 00:12:24]. But we’re winning. The point is when we make the case that I just said, people go, “Oh, okay. I get it. I’m okay [inaudible 00:12:33].”

Dr. Andy Roark:
That seems obvious to me is you go, “Boy, the impact of this on people’s ability to have pets and pay for them is just so monumental.” It would be so sad to have to make those adjustments.
Hey guys, I just want to jump in real fast and give all of my practice owner friends a heads up. The Practice Owner Summit is coming in December. It is an Uncharted veterinary conference. It is only for practice owners. It is a summit, which means plan for it to be very hands on. You’re going to meet with everyone, other practice owners, everyone there basically is going to be a practice owner. I expect we’ll have 75 practice owners coming together in Greenville, South Carolina December 8th through the 10th. This is a program that I am super happy to put on and run it with my team at Uncharted. It is unlike anything that you’ve seen before. If you want to work on your business, you want to talk with people who get it and who understand the stresses of being an owner, come on and check it out. I’ll put a link in the show notes. Guys, let’s get back into this episode.
Let me ask you one more thing before we go on. So I thought a lot about this, and we say to people, “Your pets are family, and we treat your fur babies,” and we talk like that, I like that language in a lot of ways because it’s always been about raising the human animal bond, and emphasizing people’s connections to pet, and recognizing and honoring that connection.
At the same time, Mark, as I listen to these things and we talk about noneconomic damages, and then also the inability to get pets in to the clinic, and I say, we say, “This is your fur baby, but I can’t see you today.” No shade at all for not being able to get people into the clinic. I am 100% one of those people who says, “If you have a capacity in what you can see in a day, and when you surpass it, you can’t just push your staff harder.” That’s not how this works, and so no shade on not being able to get people in. However, do we need as an industry to start adjusting the language that we use when we talk about pets? So how does that feel when I say it to you?

Mark Cushing:
I have contractors all over my property right now, so I’m just waving them off saying I’m [inaudible 00:14:48]. I’m talking to this esteemed national veterinarian [inaudible 00:14:52]. So I’m a free speech guy. I’ve always believed strongly, not just as a lawyer, but as a citizen. So attempting to regulate language to me is a fool’s mission, Andy, even if it’s well-intentioned, you’ll never quite achieve it. And we’ve used those phrases about pets for 15, 20 years, and not had noneconomic damages come back to bite us. So I think we can manage our way through it at that level. What will change is that the plaintiff’s lawyers, who are busy with opioid lawsuits, following gun control lawsuits, following asbestos, following cigarette, following just fill in the blank, where the scale of reward is billion dollars, so you get a third of a billion dollars versus $100,000. You get a little more excited.
So when that groups turns their eyes, and I’ve waited for 16 years to see when that group shows up, their lobbying power is almost unbeatable, almost. That’ll be different, we’ll see, and language may have to change. But I think for now, we can continue to do it. And the nice thing is pet owners aren’t crying for those damages. That’s the other thing. Those cases always have people that have died horrible deaths, and they’re on the ads, and it’s super compelling. Well, people know pets live short lives. So it’s a different narrative to say, “My 13 year old retriever had to say goodbye.” Well, chances are in the next year, you would’ve had to. Does that sound callous from a lawyer? Sorry, but that’s sort of the reality of it.

Dr. Andy Roark:
No, I hear that. All that totally makes sense. No, this is insightful. I appreciate your insight. Let’s evolve this a little bit, and I want to swing over to CBD. This was a topic a couple years ago we heard a ton about, and CBD was everywhere, and the CBD stores were popping up. There were just new products really coming into the vet market. And then I felt like things kind of hit a stable point, sort of an equilibrium, and they sort of were normalized to some degree, and things sort of quieted down. And now I’m hearing a lot more about the legalities of CBD, sort of changes to access of CBD. Can you sort of start to lay that out for me? Why is this becoming an issue again?

Mark Cushing:
Well, it’s becoming an issue again because so many states have legalized recreational marijuana. A majority have legalized medical marijuana. CBD’s not marijuana, but the point is the culture is much more comfortable with it, number one. Number two, you’ve seen people get comfortable using gummies and a whole host of just CBD products themselves, and particularly when it relates to stress. The argument, I don’t want to keep giving my dog gabapentin because we’re driving eight hours down to Florida for Easter or something. Is there something that’s less aggressive and maybe has less residual, potential residual issues? So there’s that, but you now have legislation, and now, surprise, California has jumped to the head of the pack. And the legal standing right now of CBD supplements in California is that there is no restriction, no restriction on a veterinarian recommending or selling it from their practice to a client.
And there’s uncertainty, Andy, you know this because you’ve podcast all over the country. There’s uncertainty all over the country by veterinarians. Can I even discuss CBD with my clients? Let me just take issues one at a time. The answer is we have a thing called the First Amendment. You can talk about space travel, you can try to tell your clients the world is flat. You can talk to your clients about anything you want. You can. I mean, the truth is you can talk about it. So there’s no thought police, speech police zooming in from a vet med board saying, “Did I hear you mention CBD? Let me have that license of yours and we’ll kindly excuse you,” number one.
Number two, the problem has been the FDA. And let me tell you what the FDA hasn’t done, and it’s what they haven’t done that’s frustrating. So Congress passed in 2018, the Farm Bill. It was signed by the president. That means the language of that bill is the law of the United States. And that law said the following, “If it’s hemp based and the THC, the psychoactive level, that high level of the CBD and hemp, is below .3, that is legal in America.” That’s legal right now. And so if a supplement fits that category, it’s legal. A veterinarian can recommend it. And in my view, they could sell it.
Now what the FDA’s done is say, “Well, we won’t pronounce on that. We won’t make a statement.” So you have one agency sitting there that everybody looks to, being silent. But they will say, “If you’re a supplement manufacturer and you make a therapeutic claim, if you claim that supplement’s going to do something good for a pet, or it’s going to change their bodily structure or function,” that’s the language they use, then we’ll shut you down because only we can approve a therapeutic product. So CBD manufacturers have gotten a lot smarter. And you just pay attention to their marketing, and they’re not making the claims that they might’ve made or want to make, the truth is. So it’s not helpful in my view, and I’ve told the FDA that. It’s not helpful for them to not just step up and say, “We know it’s the law, if you fit this category, hemp based below .3 THC, you’re okay by us.” You can say we’re not going to regulate you, but we’re not going to punish anybody for using you.
So that’s the uncertainty out there, but it’s going to go the way that human marijuana use went. State after state, including SEC states, which tend to be very conservative, other than when they’re talking about SEC football, but states increasingly are saying, “Yes, marijuana, we can live with it within our culture.” And you’re going to see that trend. And so I think what’s going to happen is more and more states are going to say, “Veterinarians, officially, you can do this.” Right now, veterinarians are like, “I don’t know. I want someone to tell me for sure my license isn’t at risk.” And I’m involved, it probably won’t surprise you, but I’m involved with trying to get some of those reforms initiated in states that clarify it. The ones that have are Nevada and California right now on the veterinary side. And those numbers need to increase. And I think once more states do that, people will get comfortable.

Dr. Andy Roark:
What do you think as far as pace of this change? I mean, so Nevada, California, is this in five years, the majority of the states? I mean, I know we’re just sort of forecasting here. But is it a couple years, or is it much longer term than that? What are you thinking as far as timeline?

Mark Cushing:
I think a five year window’s a good way to look at it. And I’ll be disappointed if we’re not at the 10 to 15 states in five years, crazy successful, 20 states. I think in 10 years, over half the states will. And again, I think if you tie it to a veterinary client patient relationship, so you’re saying, and that’s what I favor, so you’re saying, “Yes, you can recommend and dispense, and you can administer in your practice if you need to, a product that fits that legal definition if you have a VCPR with the client.” Then I think we built in a whole set of standards and care that veterinarians have to bring to bear, rather than just sort of casually recommending to a friend, “Yeah, why don’t you try this?” So I think if we have safeguards, people get comfortable. And the key to me, Andy, is that the state VMAs not come out against it, and let … And you never know until you’re in the battle whether they’re going to come out.

Dr. Andy Roark:
Yeah. That makes sense. So getting my head around this, so when we talk about manufacturers that are doing more than .3 THC, things like that, are those not available for purchase in other states? Or owners are just, I’m assuming, ordering them online, it’s just they’re not coming through veterinary clinics. Help me understand that.

Mark Cushing:
Yeah. They’re not coming through veterinary channels, and it’s probably CBD for humans. And to me, that’s dangerous. I mean, I’m a baby boomer. I’ve been exposed to cannabis in CBD in my life. That will shock people. I did live in America in the 60s and 70s and 80s and 90s and now. Point being, a lot of people, I mean, sadly, some people are just taking marijuana in some manner, feeding it to a pet, which is very dangerous. And so that’s the mistake being made there. But people are saying, “Hell, it makes me feel good, and I weigh X number of pounds, so my retriever weighs 65 pounds. I’ll cut it in third, or I’ll cut it in half, or a quarter,” and not a good plan. But there is that going on, no question.
So I think what you want to have happen is let the … And I work with a company going through FDA clinical trials right now, so once you start to have standards that people understand, I’m surprised how many veterinarians don’t know about the Farm Bill, don’t know the hemp based less than .3 THC means something. They’re like, “Oh, what’s that? I never heard about that?” Well, that’s the law. And so we kind of have to get the word out, and I’m hoping that med boards and vet medical associations are comfortable saying, “Yes, that’s okay.” But I think they’re being told by lawyers, “You’ve got to be cautious here. Wait and see what the FDA does.” And I always say to people, “We can wait.” But the truth is, federal law already says the following, which you’ve heard me say. Don’t be afraid to adhere to federal law. And the FDA’s angle is, don’t make a special therapeutic claim about it, but you can get around that. And so smart companies use language that, that’s not claiming it’s going to heal this or cure that.

Dr. Andy Roark:
Got you. Well, let me wrap this up. I want to ask you one of your future facing questions because I’m always interested in your perspective. We’re going into midterm elections. We’ve got signs of continued inflation and prices continue to stay high, even with adjustments to interest rates from the Fed, things like that. Where do you see vet medicine in the next 12, 16, 24 months? Are there forces you’re expecting to be impacting us that are not yet apparent?

Mark Cushing:
I think that the Republicans will take the House back. Whatever your party is, the beauty of that is when we have dual governments, Republicans have this, Republicans have that, but both parties have some power. The pace of federal spending always slows down, and inflation is driven mainly by just massive federal spending that puts money into the market, into the world. And everybody says, “Well, that sounds good.” But then it has the effect we’re now experiencing. I think that’ll slow down fears about a recession. What’s changed in the narrative is inflation, inflation, inflation, oh, my God. Now we’re getting near. Oh, you read the Wall Street Journal today, everyone’s saying, “Recession likely.”
I think that threat will abate. That will cause people will calm down about: Do I have to start making adjustments in my lifestyle right now? Because there’s still jobs available, so if somebody wants a job, they can get a job. But I think you’re going to see that the recession threat and the scale of inflation, if just that one thing happens, Republicans take the house because that means that the Democrats can’t simply push through a spending plan that Republicans can’t stop, so I’m being very political in saying that. There’s things about Republicans taking control that I don’t necessarily like, but that’s one positive.
So the threat to veterinary medicine is there of a recession, but it’ll be on the edges of it. I do not see people saying, “I’m not going to feed my dog. I’m not going to feed my cat. I’m going to drive my dog to the shelter.” You know why people are giving pets back to shelters now? Because they can’t get veterinary care. That threat is independent of any national election. That’s a professional saying, “We have to open up avenues for care or remove barriers to care so people can get care other than going to a clinic,” because clinics have said, “There’s no room at the inn. Sorry, there’s just no room at this hotel. You can’t stay here.” So I’m less concerned for this industry than others about how a full on recession plays out. It’ll slow some things down for sure, but look at what’s happened.
Market Watch shows us every week that vet spending’s up from a year ago and up from the year before that, so that’s my one political ad for this interview, is that I like divided governments. You know why? Because it forces the extremes of both party, which drive most people nuts, myself included. It forces extremes to have conversations because you just can’t yell at each other all day if in fact nothing can happen if you don’t sit down because one side has to get buy in, and the other side has to get buy in, so that’s my hope. If not, I will tell you, it’ll be pretty interesting what’s going to happen. Tighten your seat belt and watch out.

Dr. Andy Roark:
Awesome.

Mark Cushing:
You heard it from the oracle. Yeah, there you go.

Dr. Andy Roark:
Mark Cushing, you are the author of Pet Nation. I’ll put a link to the book in the show notes for those who’ve not checked it out. There’s a podcast you and I have done in the past about it. It’s a very, very interesting read. I really enjoyed it. Where can people follow you? Where can they read more of your writing and your thoughts?

Mark Cushing:
Well, they can go to, I think it’s markcushing.com or marklcushing.com. I can’t remember if I have my dad’s middle name, Lewis. But animalpolicygroup.com for our business. And then Pet Nation, you can get every way possible. And if you like the sound of my voice, for some reason, you can get the audio version. And as you’re walking on the beaches in Carolina, you can hear what I have to say.

Dr. Andy Roark:
It’s like I’m walking on the beach with Mark Cushing, and it doesn’t get better than that.

Mark Cushing:
How could you top that? I agree. So Andy, great seeing you. Great questions, as always. You’re ahead of the game, and you just pull the rest of us along, so thanks a lot.

Dr. Andy Roark:
You’re very kind. Guys, take care of yourselves. And that is our show, guys. That’s what I got. I hope you enjoyed it. I hope you’ve enjoyed hearing thoughts and ponderings of Mark Cushing. As I may have mentioned before, Mark is the founder and CEO of Animal Policy Group. His opinions are his own, although I do very much enjoy hearing where his head is and hearing him talk and predict the future. So anyway, I hope you guys having him on here. Check out his book if you get a chance. Yeah, and that’s it from me, gang. Take care of yourselves. Be well. See you next week. Bye.

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

Referral Battles When Everyone is Overwhelmed

October 26, 2022 by Andy Roark DVM MS

Dr. Tannetje’ Crocker, a practicing emergency room veterinarian and social media personality, joins Dr. Andy Roark to discuss how work overwhelm is pitting emergency vets and general practitioners against each other.

Cone Of Shame Veterinary Podcast · COS – 167 – Referral Battles When Everyone Is Overwhelmed

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

LINKS

Uncharted Practice Owner Summit: https://unchartedvet.com/practice-owner-summit-2022/

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/on-demand-staff-training/

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ABOUT OUR GUEST

Dr. Tannetje’ Crocker is a 2009 graduate from the Texas A&M University College of Veterinary Medicine. She is passionate about mentorship and empowering veterinary professionals to embrace the profession and find joy and success. Growing up Dr. Crocker competed on horses and was inspired to become a veterinarian. Since graduation she has worked as an equine ambulatory vet, small animal general practitioner, and emergency veterinarian. She currently lives in Texas with her spirited 10 year old daughter, funny 6 year old son, and supportive husband of 16 years.

She works as an ER Veterinarian for Veterinary Emergency Group in Dallas, TX. Recently she was excited to purchase Alta Vista Animal Hospital in Fort Worth, TX. She plans to continue her support of fellow veterinary professionals, both virtually and in person through her various endeavors.

Follow her veterinary journey @dr.tannetje.crocker or www.drcrockerpetvet.com


EPISODE TRANSCRIPT

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

Dr. Andy Roark:
Welcome everybody, to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great episode here today with my friend, Dr. Tannetje Crocker. We are talking about interactions between general practice, veterinary care, and emergency veterinary care, and we’re talking about it in the sense of being overwhelmed. What does it look like? What does it feel like when the GPs have too much work to do, and they’re giving it to the ER, and the ERs have too much work to do, and they don’t have anywhere to give it back? And how do we feel about each other, and how do we talk to each other, and how can we make this better? Guys, those are some of the things that we talk about today. 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. Tannetje Crocker. Thanks for being here. I met you when you accosted me outside of a bar in Orlando. I was leaving and you said, “Hey, Roark, I’ve got a beef with you.” That’s what I remember.

Dr. Tannetje Crocker:
That’s a variation, but I’m not going to say you’re wrong. I’m not going to say that you’re wrong.

Dr. Andy Roark:
No, and I will say that’s how I met a lot of friends in my life with people who were like, “I have a beef with you,” and you took issue with something that I had said about TikTok and you were like, “You miss the advantages of TikTok and you miss the good that it can do,” and I honestly ended up thinking a little bit differently about TikTok, after talking with you. And so, I’m very interested in the work that you’re doing. So, for those who don’t know Tannetje, she’s a practicing emergency veterinarian. She also has a fairly active social media presence. She’s got almost 50,000 followers on Instagram. She’s doing TikTok now for just about a month, and she’s got about 80 some thousand followers on TikTok. She’s doing a lot of interesting work with social media, and guys, she’s doing it in a really positive way.
So, it’s nice. The reason that I have really enjoyed getting to know you in the last probably six, eight months, is the work that you do is good in that you’re positive about our profession. You’re not using social media to crap on what we do, or complain about how bad things are. You’re actually out there talking about the things that you like, and things that are actually helpful, and things that might make other people enjoy our profession. And so, I just want to start and say, well, first of all, thank you for doing that. It’s something obviously that I care a lot about, and it’s just refreshing to see somebody out there who’s doing emergency medicine, and who’s still determined to find the positivity and to present it to the world in a positive way, so thank you.

Dr. Tannetje Crocker:
I appreciate that, because that’s definitely the intention. When I first joined social media, it was literally because I was frustrated with everyone saying, “You shouldn’t have become a veterinarian,” telling vet students they made a wrong decision. Can you imagine being in that school and someone saying like, “Hey, wrong decision. You really messed up?” And so, my message, I guess, resonated with people, and now I just get to have a lot of fun with it, really connect online with people, encourage them, and I don’t sugarcoat anything. I mean, emergency work is hard, I talk about the realities of that, but I try to bring it back to the choices that I’ve made that have made me still really, really enjoy and love it after 14 years, and hopefully encourage other people to find their joy in this profession, which can be hard.

Dr. Andy Roark:
Yeah, we’ve hit this weird tipping point in medicine talking about students. So, this is 100% just my perspective of things that I’ve seen, and I think a lot of people are like, “Vet students, they need to understand the harsh realities of the choice they’ve made,” and that might be true, but the truth is, there’s a lot of people who have had that idea, and then they go to the vet students and they’re like, “This is going to be real hard,” and if everyone’s telling them it’s great, and one person tells them it’s going to be hard, that’s probably a good thing, but if everyone tells them how hard it’s going to be, at some point, it’s just soul-crushing and not helpful.
And I feel like we have, in a lot of ways, have crossed over that line. Not to say it’s not hard, but boy, I have seen instances where I’ve really feel like vet students have just been pounded on for months and months of people talking to them about how hard the profession’s going to be, and at some point you go, “Let’s also make sure that we’re giving air time to why we got into this, and to the good things about it,” because there are good things about it. And so, anyway, that’s sort of my take in talking to young doctors these days.

Dr. Tannetje Crocker:
I would agree, and we’re not here to talk about this, but I would say, wouldn’t it be great to give them ways that you’ve dealt with those difficult things, and how you’ve kind of pushed through those hard times, versus just saying, “Hey, you’re going to be stuck there forever.?”Let’s give them the resources to find the success and sustainability, and not just say, “Nope, this is how you’re going to feel.”
And when especially people talk a lot about the tough clients, I will go to talks at vet schools and they’ll say, “How do you handle this? Oh, I’m so worried about this,” and I will tell them, “I see a ton of people in the ER in a week, and I don’t have those interactions 100% of the time. That is a very small percentage of those interactions in a very high stress, difficult time. So, don’t focus on that. Let’s focus on all the things that you do good and all the great things that happen, and let’s talk about gratitude and strategies, versus let’s focus on that one horrible client that happened in a three month time period.” And that’s where social media really, that vocal minority that’s telling them, “Yeah, it’s going to suck, and all the clients are horrible,” I don’t know, it’s really tough on them. So, I’m glad that people like you and me are out there, and I heard a rumor that you might eventually be joining TikTok with me, and so, maybe we’ll spread the word even more.

Dr. Andy Roark:
I-

Dr. Tannetje Crocker:
You’re thinking about it.

Dr. Andy Roark:
I am thinking about it. I have a notebook of things that I have been jotting down. I’m not going to do something just to do it. If I’m going to do something, it needs to be good in my own eyes, and I also have to approach it from a way where I go, “I enjoy doing this, and this has value,” and I’ve been thinking about it for a long time, and just sort kicking around that little notebook of things I jot down where I say, “I would be happy to do this,” or “I genuinely think this would be helpful.” And honestly, I think you have been a piece of me getting more open to that idea, just because I see you and I go, “Nah, she’s doing a good job. I got to say, she’s doing a good job,” and that makes me think, “Okay, this may be a worthy problem to sit with for a while.” And so, yeah, you’ve definitely moved me in that way, but I’m not making promises, but it’s on the radar.
The last thing I want to say on this is, not on TikTok, a healthy problem looks like this: There’s a problem, and then the first step is raising awareness about that problem, and then the second step is now that awareness has been raised, it is coming up with actionable, productive steps to take to manage or to treat said problem. And I feel like in the world of social media, unfortunately sometimes we get stuck in action step number one, which is raising awareness, where we raise awareness, and we raise awareness, and we raise awareness, but actually taking steps to do things in the real world, that gets lost on the way, and raising awareness gets a lot of attention, right? The things that drive attention are fear and anger, and we can raise awareness with fear and anger, but fear and anger don’t turn into productive action steps.
And so, I really do think that you’re absolutely right. I think we’ve done a good job of raising awareness of challenges of medicine, and challenges to mental health, and that stuff is good, and we should keep that, and at the same time, I think it’s also very important that now while people are raising awareness, they transition to step two, which is, “Here’s some things that have been helpful to me,” not “This is what you have to do, but let me share with you what has been helpful for me, or lessons that I have learned,” and I think that’s a positive place to be. All right, but that’s not why you came here. It kind of is. Things are hard.

Dr. Tannetje Crocker:
Oh sorry, my dogs are barking.

Dr. Andy Roark:
They’re excited. So, here’s why we’re here, because vet medicine is hard, and I want to talk to you about a specific aspect I think is really challenging that I see again and again, and it’s the interaction between general practices and emergency practices. So, let me tell you what I kind of see from my side, on the general practice side. Basically, a lot of our practices are overwhelmed. There’s a general shortfall in the amount of labor that we have, and that’s in trained and untrained, but I mean, licensed doctors, and technicians, and support staff. All across the board, we’re having worker shortages, and we have very, very high demand. And so, there’s a caseload that is not able to be met in the general practice, and they’re referring that away to the emergency clinic.
And so, when I talk to these practices and they say, “Aha, I am overwhelmed and my staff is burned out, the answer is I need to refer these things away, because we simply can’t see them,” and I completely agree with that. You cannot see more than you can see. We all have a capacity, and if you push past it, there are very negative outcomes that happen, especially in the long term, and so, that is true. Ultimately where the conversation goes is, “I’m referring these guys to the emergency clinic, and there’s a six hour wait or an eight hour wait, or our emergency clinic is not taking animals, what do we do now?” And that’s a hard question, but that’s what I kind of want to start to unpack with you a little bit. So, let me sort of open up to you in that way and say, when I tell that story, does that resonate with you? Is that kind of what you see? Have you come across that narrative?

Dr. Tannetje Crocker:
Definitely have seen that, and it’s interesting, because I’ve seen it from the general practicing veterinarians, I’ve also seen it from the local specialty clinics. So, we will have specialty clinics call our emergency facility and say, “What’s your wait time? We have a packed room, ours is this. Can we send people to you?” And so, it’s not even between general practicing vets and emergency clinics in general, it’s everybody right now, and I think there’s a little bit of a public Amazon effect. So, more and more pet owners want really immediate results. They also have greatly changed the way they look at their pets, and what level of care they want for their pets, and so, they’re more likely to take them in quicker for things that maybe previously, they would’ve waited through the weekend to see their regular vet for, or they know their regular vet is already booked out two weeks, and they’re not going to see them, and so, might as well go to the emergency clinic.
I would say from my perspective, if an owner is concerned and they’re willing to wait, whatever the wait time is, then I’m going to give them my full attention, and I’m going to help them to the best of my ability, no matter why they’re there. So, if it’s a broken toenail, if it’s they vomited once, I’m still going to try to help them in any way that I can, because I’ve been that pet owner, and something happens with my pets and I can’t even process it, right? Another vet has to take care of it because my mind just… And so, I put myself in their shoes and I want to help them, even if I feel like this probably isn’t a true emergency, it’s not a hemoabdomen, it’s not respiratory distress.
So, I think we have to change a little bit perspectives on both sides. One, I would love to see the general practices train clients a little bit better that wait times are not a bad thing, and what is a true emergency, and not just use the ER as I guess, a dumping ground a little bit, for the things that they don’t want to deal with. And then two, I think that as emergency veterinarians, we have to learn how to communicate that we still care and we want to help pets, without making owners feel like they are silly for coming in or they are wasting our time, because I don’t think that’s fair to them either. Sometimes they just don’t know, and I like the phrase, “This is in good intent,” right? So.

Dr. Andy Roark:
Sure. No, I definitely get that. I have a buddy who tells a story about, he’s not a vet person at all, and his dog was reverse sneezing one morning, and he came sprinting to my house and he was like, “You saved my dog’s life,” and I was like, “I did not. There was nothing urgent emergency about any of this.” But he was like, “I don’t care. I was terrified, and then I was not terrified anymore, because you talked to me and you looked at me, and you told me everything was okay, and then it was okay. And so, you did the magic, you did the thing,” and I was like, “Okay, I get it.” It’s interesting to think from his perspective yeah, that knowledge that really matters. Tell me about what constitutes, because this is an interesting topic, what constitutes the feeling in the ER of a dumping ground? What makes people at the ER feel that they’re being treated that way? Because I want to unpack that a little bit, and see what makes up that emotion.

Dr. Tannetje Crocker:
Let me give an example. So, we had someone come in late two nights ago, and they had been at the football game, they were a little tipsy, they had a really good time, but they came in, rushed in with their really young golden retriever puppy, she was adorable. This puppy looked amazing, she looked great. She had been boarding while they were having a weekend at the football game, and apparently the boarding facility did a fecal, and they sent the owner a message afterwards that said, “It’s a positive fecal, and you need to get it checked out.” And so, the owner called the regular veterinarian, and it was a Saturday and the vet was like, “You need to go to the emergency room.” And this was a-

Dr. Andy Roark:
Oh my god.

Dr. Tannetje Crocker:
… completely normal puppy that had no diarrhea, that was eating and drinking well. It could’ve waited until Monday, but they freaked the owner out and they said, “Well, just go to the ER, they’ll take care of it,” and we were a little surprised that they wouldn’t at least get the fecal results, talk to them about it, maybe prescribe medications. I mean, they already had a relationship with her, but it was the feeling of they just didn’t want to deal with it on a Saturday, and we’re there and we’re open. So, we did, and we saw the pet, we actually got a negative fecal in house, so that was interesting. But it’s those types of circumstances where they don’t want to tell the owner no, so they give them the option of coming to us for something that they probably could’ve set appropriate expectation for.

Dr. Andy Roark:
Yeah. I think that’s really interesting, okay? So, here’s where I’m really tied up, is I want this profession to work for everybody, I really do. That’s super important to me, and there is a nightmare scenario where imagine that the pets are a stream of water, and we’re just pouring from this bucket, and we’re pouring down onto the general practice, and the general practice is completely full, and the water’s now pouring over the top of the general practice, and down into the emergency practice, and now the emergency practice is overflowing, and then the question then is, where does that water go? The water that is now overflowing past the emergencies, where does that go? And I think in the nightmare catastrophic scenario, in the minds of emergency vets it’s, “I never go home, I just stay here. I stay here through the day continuing to work in triage, and I never get to go home.”
That’s not possible. And so, I’m thinking a lot about that. I think there are limits to what we can do. We can’t magically make more veterinarians. I can’t just be like, “Voila, here are 10,000 more emergency vets,” and a lot of people are like, “You can’t, are you sure? You should try, at least try.” There’s nothing that we can do. We’ve got what we’ve got. I believe that we have to move these cases around more. I think that there’s a lot of things that we can do, and just like you and I were talking about before, at some point, you raise awareness, and then you have to come up with action steps. And so, awareness of, “Boy, we’re all really, really busy, and there’s big wait times in a lot of emergency clinics.” Let me also pause here for a second and say, this is 100% regional, in my experience. There are some places where they’re like, “No, we got this, we’re fine,” and there’s other places where they’re not fine. And so, if it’s not happening in your area, that’s great. Know that it’s happening in other areas.
So, I like your idea a lot. That’s actually one that I’ve had in my list of trying to set realistic expectations of what is an emergency, and put some time and space there. My family’s had some illness stuff recently we’ve been sort of working through, and so, we’ve been getting to deal with the joys of human medicine, and let me tell you, they do not tell you to rush in. They do not tell you that you should go… You can have some serious problems and they’ll be like, “We’ll see you a week from Wednesday,” and that’s it.

Dr. Tannetje Crocker:
Yes.

Dr. Andy Roark:
And they say it to you with a straight face, and it’s normal, and they’re just like, “That’s just what it is,’ and it’s amazing to me coming from vet medicine, I am like, “Are you serious? 10 days before we do the next thing?” And they’re like, “Yep, that’s what it is.” And again, I do not want us to be human medicine. At the same time, you can’t tell me that we cannot set some deadlines down the road sometimes, and have them be okay.

Dr. Tannetje Crocker:
I think that there’s actually quite a few very practical things that we can do on both sides. So, at our emergency clinic, we actually answer phones after hours for a lot of the general practices that sign up for our program, and those phones ring through to us, if the owner calls, and it says, “In case of emergency, push this,” and we will talk to the owner about what’s going on. Sometimes they’ll send us a picture or video, and very much triage in that way. And so, I’ve had quite a few that I’ve said, “think you can watch for A, B, and C. If that happens, come in. If not, call your veterinarian in the morning.” And so, people feel heard, people feel seen, they feel calmed, but they’re not rushing in for something that they could watch for a couple hours. And so, I think that’s one option that would help practices out a lot more, if there could be some more sort of tele-triage option.
And the other thing is scheduling-wise, I’ve worked in GP and ER, I know that in GP, you want to make the money, you want to make sure your schedule’s full, you have people there, but there’s been a lot of discussion of how to schedule, making sure that there is room open for those same day urgent emergency type cases, and knowing again, what is a true emergency and what absolutely needs to come to us right away, versus what can you triage and treat, and then see how it does? And so, both sides could do a little bit better with communication, with I guess supporting each other. Like that dog that came over that had the parasite, supposed parasite, I will never say, “You shouldn’t have come.” I will never throw a general practice under the bus, right?

Dr. Andy Roark:
Right. Mm-hmm. Sure. Oh, totally. No, no, no.

Dr. Tannetje Crocker:
I’ll support them no matter what. But on the flip side, I have GPs that’ll say, “I can’t believe that you guys didn’t see them, or you didn’t do this, you didn’t do that.” And so, I think that’s a little bit of the issue too right now too, is what does the client tell them happened or didn’t happen? And so, I’m seeing a lot of general and emergency practices struggling, because they feel like the cases aren’t handled the way that they would handle them. And so, then when you feel that judgment, you kind of feel like, “Why am I staying open? Why am I staying two hours after my shift to see your patients, if you’re just going to throw me under the bus or you’re going to question what I’m doing?” So, I don’t know if you’ve seen that, but I think that’s another component of this that makes it hard to work together.

Dr. Andy Roark:
Oh, 100%, the Monday morning quarterback. I’ve been that guy who comes in on Monday and looks, and I’m like, “Oh, [inaudible 00:19:42] emergency clinic. Let’s see what they did,” and I have seen vets get their reading glasses out and I’m like, “You don’t read anything that closely,” but they’re like, “Let’s see what happened here,” and they look. And again, it’s easy to look at someone else’s work and be like, “Well I wouldn’t have done it that way, or blah, blah, blah.” I think that there’s areas of this that are just fine, and they’re just human nature. I think that there’s always a bit of insecurity that people have when someone else sees their case, right?
So, it’s like, “You saw another doctor,” and in my little fragile heart it’s like, “I bet they liked her more than you. I wonder if she thinks that what you did last time was not good. Does she have the records? Is she looking at what I have done in the past and been like, “What is this idiot thinking?” I hope not, but I think we all have that little bit of insecurity as well. And so, we want to look and see like, “Oh, did they do what I would’ve done, or did they follow suit with what I said?”
So, I really do think that that’s a big part of it. There’s part of that that’s normal. There’s a part of that that’s not normal and not helpful, and part of it is I think if you’re going to use an emergency clinic, which we all do and we all should, then you have to one, assume good intent, as you said earlier, which is, I’m not there. I don’t know what the pet owner said to them. I do not know what state the pet owner was in. I don’t know what the pet looked like when they walked in the door. I can look at where they are now and I can hear the story, but that may not have been what that vet was looking at at that moment.
And so, I always try to give grace and say, “I wasn’t there, I didn’t see it,” and I’ve seen cases change. I’ve seen them where I’ll see them in the morning and I’ll say, “Hey, if this doesn’t get better, come back, or blah, blah, blah,” and they’ll come back at the end of the day and I’ll be like, “Oh my god, this is three hours’ difference or this is four hours’ difference?” Things can look radically different.
And so, there’s that part of giving grace, but I do think a lot of us, and I’ll tell you this is a general part of our profession, are perfectionists, and it needs to be done just right, and it needs to be done the way that we would do it, and I think that that is a constant struggle, I’m sure for emergency vets. Like I said, it’s not a position I’ve held, but I know that there are perfectionists who get cases back and say, “Well, this is not how I would’ve done it, this is wrong.” And I think really, part of being happy as a veterinarian, is it sucks that being a perfectionist is what helps you ace vet school, and gets you into vet school, and gets you through vet school, and then as soon as you’re out, it’s a burden, it’s a crutch, it’s a pain, because being a perfectionist limits your abilities to delegate.
I think it makes it hard to leverage your technicians, as much as you can leverage them, and it makes it hard to work with emergencies and support services, and to refer, and things like that. And people say, “But if you’re a perfectionist, that means you’re doing it right,” and then it’s like, well, at some point, when you’re dealing with large numbers of cases, perfect is the enemy of done, and I would say if you’re overwhelmed and you need to get the work done, and you’re trying to help as many patients as you can help, having such high demands that no one else is deemed worthy to help you, that is career limiting, and it is going to be a long-term harm to your mental health.

Dr. Tannetje Crocker:
Definitely, and I work a lot with new grad veterinarians, we have a training program that’s really intentional in our ER, and so, that is one of the main things that I have to teach them is number one, why is the pet there? What is the owner’s concern, and let’s actually focus on that, right? Yes, this is a 15 year old pet that probably has multiple disease processes going on, but why are they there? Let’s figure out how we can help that problem in this moment. And then number two, you’re not always going to know. So, you’re not going to know maybe why that dog vomited. It would be great to do full workups on every single pet, but that’s just not the reality of people’s finances sometimes, or your time constraints and what you have going on.
So, you have to make your best guesses sometimes, and you have to be comfortable with that, and knowing that if it’s not better, it’ll get rechecked, but I see that, and I don’t know if you’ve seen that with the younger generation, where they really want to know, they have to have an answer, they want to want to fix it right away, and that ability and that maturity kind of as you get in your career and sit back and say, “This is not actively dying. I think it’s going to be stable for a little bit. Let me try A, B, and C. If that doesn’t work, then they can reassess and recheck with their vet, and move on to plan D,” is perfectly acceptable.

Dr. Andy Roark:
Guys, I just want to jump in here real quick with one quick announcement. If you’re a practice owner, the Uncharted Practice Owner Summit is coming. It is me and my friend, Stephanie Goss, the practice management guru. We are going to be leading that, heading that up. It is in person in Greenville, South Carolina. If you are a owner and you’re like, “Man, I want to go to a thing that’s only practice owners and work with other practice owners,” head over to unchartedvet.com, and check out what we’re doing. Guys, that’s it from me. Let’s get back into the episode.
There’s two pieces to this, right? and I think you put your finger on it it. First of all, let me just call out the fact that you and I are 100% having a deep conversation about spectrum of care, which is what is the gold standard, and then-

Dr. Tannetje Crocker:
Very true.

Dr. Andy Roark:
… what is a perfectly acceptable lower standard that works for this client in this moment, with the resources that we have? I think that I like that terminology, I think that that’s really important. But yeah, I think a lot of people have said, “Only the best care, only the best care,” and I’d say, “Look buddy, when we’re 30% shorthanded and we’ve got more work than we can do, we’re going to provide a standard of care up to what our practice standard of care is.” We need to decide what is our standard of care here, and we can provide up to that. But beyond that, at some point you have to say, “This is what we’re going to do today, and then we’re kick the can down the road.”
I think about it sometimes. I went to a chiropractor one time a long time ago, and I said it was a chiropractor, it was a physical therapist. I went to a physical therapist years ago and they said, “What’s wrong?” And I said, “I have plantar fasciitis that’s flared up in my foot. Also, I hurt my shoulder yesterday,” and she looked at me and she said, “Which one do you want to work on today?” And I thought that was fascinating, because in vet medicine, we would’ve been like, “We better get going fast, because now we’ve got 100% more things to do.” And it’s just a simple thing of “Which one are we doing today?” I go, Wow, that’s some boundary setting, and it’s smart, because we’re going to actually make some progress on one of the things.And so, I don’t think that we do that very well. I also completely agree with the education of veterinarians, is we’re taught gold standard of care, and we’re taught by specialists and we come out, and then there’s this idea of we have to get it right, we have to practice the top standard, and we have to get a diagnosis today, and I really do think two things that we don’t learn in vet medicine and we don’t learn in vet school are how to break apart problems and triage, and handle the first thing, and then work on the recheck, and then work on the recheck. And again, to give grace to the vet schools, they’re working with specialists, and they are teaching people the highest standard of care, and if you did that, then rotations would be really frustrating, because you would come in for two weeks and you would see someone’s third visit-

Dr. Tannetje Crocker:
[inaudible 00:26:52].

Dr. Andy Roark:
… and that’s all that you would see. It’s not how you want to learn, but I do think that that is a part of it, and then the other part, I would say that is a real struggle in vet school, is how to leverage the staff, because they train you to be the doctor and to know all the things, and I think it’s a real challenge to say, “You are the doctor and you know all the things, and here’s how you delegate those things away to other people, and here’s how you take help,” and I think that those are things that right now, we don’t have a good training system for those things.

Dr. Tannetje Crocker:
I’d agree, and earlier when you said everyone’s looking for veterinarians, honestly, give me two, three good vet techs, and I can get a heck of a lot done. I would always love another veterinarian, but I will tell you that the team that I work with in the veterinary ER, those technicians, they do it all, and they’re incredible, and they help me so much every day, and I would love other vets, I enjoy working with other vets, but man, give me more of them, 100%.

Dr. Andy Roark:
Oh yeah, absolutely. No, I am right there with you. I’ve got this idea, I’ve been thinking a lot about capacity in vet medicine, and so, we’ve got all these cases coming in, and most of us are shorthanded, and I hear a lot of people who just say, “I don’t know how to get this done. I don’t know how to hand these things off. I don’t know how to turn people away.”
We just finished up our GSD conference for Uncharted, which is How to Get Stuff Done When You’re Shorthanded, and it was really, really great, and the big spoiler alert, one of the big takeaways really is you have to work on your business as well as in your business, meaning you have to step back and make systems, and figure things out. At some point, you can’t just flail around working hard, you have to stop and get organized, and communicate with your people and say, “Well, what are you going to do, and how do we work together so that the sum of our labor is greater than just us individually flailing and working as hard as we can?”
And one of the big questions was, “How do I make time for that when I’m so busy?” And so, the idea that I’ve had recently, I’ve been kicking this around, and it’s still sort of fetal idea, but I think one of the ways to really look at this stuff well is to strip the emotion out of it. And so, imagine that veterinarians are widget makers, right? They’re widget makers, and a veterinarian and a widget maker can make say, 700 widgets in a day, right? That’s what they can make. If you live in a community and they need a thousand widgets a day, and you can make 700 widgets a day, what are your options? What are you going to do? And I think that that’s an interesting thing to think about, and unfortunately, what a lot of people say is, “I will sacrifice my body, mind, and soul, and the people around me to bend reality, and burn up our machines and our systems, and make a thousand widgets. We will do it by strength of will.”
And I go, “Oh really? What will you do the next day?” And they’re like, “I’ll do it again, and I’ll do it the day after that,” and I’m like, “Oh, that seems like a bad long term strategy,” and it is. But you think about what actually would work, you’d say, “Okay, honestly, increasing capacity, getting technicians in there to help you make widgets, to delegate”. If you can’t get another widget maker, which is a veterinarian, get more people to help you make the widgets that you can delegate to, and try to increase your efficiency.
Another part is to say, “The community’s going to have to wait for their widgets, because we can only make 700 a day, which means they’re going to have to figure it out or they’re going to have to get their widgets somewhere else,” and vets go, “Oh my God, somewhere else?” And I’m like, “Look, man, this is hard choices. They need a thousand widgets. You can make 700. Do you want to have angry people yelling at you because they didn’t get their widgets, or do you want them to go somewhere else and get them?” And my advice is to have them go somewhere else, because you’re selling every widget you can make. You’re not hurting for customers.
And I understand that people don’t like this analogy probably in a lot of ways, because it does strip out all the emotion. You’re like, “They’re really adorable widgets, and people really care about these widgets,” and I go,” That doesn’t change the widget math,” right? Honestly, the fact that these widgets are family members, that does not change the math. You can make 700, they need a thousand. We’re going to have to figure this out, and that’s probably going to mean that they’re going to have to go somewhere else, or they’re going to have to come back down the road, or we’re going to have to figure out who needs widgets the most, and the rest of the people are going to have to wait. But I don’t think that we want to make those calls, and that’s why I think this is a useful analogy, because I think a lot of us, all we can see are the pets and we’re like, “There’s no alternative but to just get the work done,” and I go, “That math doesn’t work.”

Dr. Tannetje Crocker:
It doesn’t, and eventually, you burn out, and then nobody gets widgets, right?

Dr. Andy Roark:
Right, yeah.

Dr. Tannetje Crocker:
And that is a huge issue we’re noticing. That’s ultimately your other option, and that’s not one that any of us want to do.

Dr. Andy Roark:
I’m really big on virtual care right now. I mean, there are a number of companies that help with virtual work. There’s virtual CSR companies, there’s GuardianVets, and Chronos, and some companies like that, that their whole job is, “Hey, we’ll take over your phones at the end of the night,” or “We’ll help provide virtual people for the front desk,” and I’m like, man, I think that stuff is so valuable, and I’m sure there’s a lot of people who like to do the virtual work, and boy, we’ve got needs for it. But what you and I are talking about as far as setting expectations with the pet owners, doing tele-triage when we say, “Is this an emergency, or can this wait until tomorrow morning?” I think that that stuff is really, really valuable.
When you were saying, “Hey, I felt like we got sort of dumped on and this person said, ‘Well, I don’t want to deal with it on Saturday, and so, I’m just going to send them straight to the emergency clinic,'” I love the idea of having a service that takes your phone calls, who can do triage, and the truth is, I would rather see that patient myself, than have them go to the emergency clinic. I would like to be the one to talk to them. I don’t want them to go wait for eight hours on a Saturday. I don’t want them to pay emergency bills, which are totally justified, but I would rather save them that money and that time, and for me to be the one to work with them, we just need to figure out a triage system. And I say they turfed them, I think I’m assuming bad intent when I use that language, and I don’t mean it that way, but you get the point. I don’t know. What are your thoughts on virtual workers in vet medicine?

Dr. Tannetje Crocker:
I think that it serves a couple needs. I think one, it definitely helps with the triage, and the overflow, and overcapacity issue that we have. There’s no doubt. When I have a sick child, I call my pediatrician, the nurse calls me back, we go over the symptoms, and they tell me it can wait, or to go to the ER. It’s a very similar model that we deal with consistently, and I think one that is very fair in human medicine. The other component of it though, is it opens up another whole range of positions and jobs, and even increasing the financial means of support team members. And so, a lot of these companies that provide those services are using technicians or people that are from veterinary medicine that want to work from home, or want to continue to make money in this space, or can do that along with the job that they already have.
And so, by opening up more positions in our profession that help pet owners and also help the hospitals, I think that’s a win-win, and it’s frustrating to me, because I think ultimately, the issue is trust, right? That a lot of the general practices want to see their own people, they want to help their own people. They don’t trust that things are going to be done their way, and that ultimately is hurting them in the long run. And pet owners, they do love their veterinarian, but in that moment, they don’t care. They don’t care who they talk to, they just want to talk to somebody, so that they can sleep. And I always say, “If you’re not going to be able to sleep, you come right in, but you also can watch for these things, and then you can see your vet in the morning,” and 90% of people say, “Okay, I’m going to watch for those things. Thank you so much. Thank you so much for just talking to me. I just needed to talk to somebody.” And so, that tells me that that model works, and I think it helps both sides.

Dr. Andy Roark:
Yeah. No, I do as well. It’s funny, I do think part of it is trust. I think another part of it is there’s a scarcity mentality that veterinarians have that has been bred in, which is this idea of like, “At some point, the pet owners are going to stop coming, and then I’m going to go out of business, and no one’s going to want me to help, and I’m going to get buried under my student loans, and I’m going to live in a cardboard box in the forest,” and that’s where this all goes. And that’s why I feel like they struggle so much to tell people “Just go to the emergency clinic,” or, and this is controversial, but it’s what I believe, tell them to go to another general practice, and people go, “That’s heresy. That’s the sacred cow, Andy. You are slaughtering the sacred cow.”
It’s like, look, man, if you’re slammed from dust until dawn every day, who the heck do you think you’re competing with? If you can’t see them, tell them to go down the road. The kindest thing that you can do is direct them to a place where they can get care, and they’ll probably come back, or maybe they won’t. But trust me, you’re never going to go to a business because there’s not enough work to do. If you’re doing good quality medicine and you treat people well, and you earn their trust and you’re a good steward of their trust, you, my friend, will be as busy as you want to be for the rest of your career. You will. There is no risk in sending people away.

Dr. Tannetje Crocker:
I agree. And as a pet owner, I would say that if I call and I’m worried, and you just say, “Well, we don’t have anything for you, and there’s just no options,” right? It’s a, “In two weeks, we can help you,” and there’s nothing, there’s no compassion, but if I say, “I am so, so sorry you’re dealing with this, and we would love to be able to fit you in, but we honestly can’t, but I know there’s other practices in the area that might have some availability. Why don’t you call A, B, and C? We’d be happy to send the records, so they know.” I’m going to come back to you, because you cared enough to give me another option and to listen to me, versus just drawing a hard line, or sending me to the ER, like you said, where it costs a lot more, if there’s another option during the day. So, I would come back to that practice personally, because they actually cared.

Dr. Andy Roark:
No, I completely agree. I think here’s the thing, right? They called you for help, and if you say, “We can’t get you in,” you’re not helping. If you say, “We can’t get you in, however, I do have some other practices that I can point you towards who may have availability, A, B, and C,” and you give some sort of endorsement and sort of say, “These are good practices and these are places to go,” then to me, you are checking that helping box.
The other thing is imagine it’s a restaurant. Imagine that there is a awesome restaurant and you want to go there, and you go there and they’re like, “We do not have any availability tonight, but there’s a couple other restaurants in the area that I would recommend.” I’m still going back to that restaurant. The fact that I can’t get in there tonight, makes me want to go there more, quite honestly, but I do appreciate getting pointed to some. I do appreciate getting pointed somewhere else.
But I think that’s just a shift in mentality, but you have to really buy into the widget idea, this idea that, “I have capacity, and if people are demanding widgets beyond the capacity that I can make, they’re just going to get mad and they’re going to get angry, and they’re going to stomp off somewhere else, and I can refer them somewhere else, and hopefully keep that goodwill.” But at some point, I really do feel like we’re holding on to the workload that we have, as it drags us like an anchor down to the bottom. So, that’s that.

Dr. Tannetje Crocker:
Yeah.

Dr. Andy Roark:
Well, Tannetje, thanks for talking through this with me. Any final thoughts, any words of wisdom, anything else you want to put forward as far as GPs, ERs, collaboration, working together?

Dr. Tannetje Crocker:
I would say that I’ve been on both sides of things. I’ve been a general practicing vet, I’m a ER veterinarian now, and I definitely think this profession as a whole, if we all work together, trust each other, and together set client expectations appropriately, while still showing people that we care about them and their pets, I think it’ll be better for all of us in the long run.

Dr. Andy Roark:
Yeah. No, I completely agree. I think right now as a profession, we’re all in this together. We need to be communicating with each other. We need to be passing the ball. We need to be assuming good intent. We need to think about how we can communicate with pet owners, and set realistic expectations. I do not think that the business model for us anymore can be put your head down, and work as hard as you can, and collapse into bed at night. That is not a sustainable business model. It does not work anymore. It needs to be, think about working on your businesses, it’s thinking about what your capacity is, how many widgets you can make comfortably and sustainably, and then making that many widgets, and then directing the overflow to the most productive place you can, and then also creating expectations with clients when they say, “All right, well, I’m not getting in for a wellness appointment for a couple weeks.”
That’s okay, man. Your dog’s not going to burst into flames because it didn’t get its leptospirosis booster right on the day that it was due. That’s it. We can also start to reach out with our reminders earlier, knowing it’s going to take people longer to get in and say, “Hey, go ahead, and it may take a little while to get in, so I’m going to put this on your radar.” All those things, those are the types of thoughts we should be having is, how do we pace ourselves for the marathon that we’re in, so that we don’t burn our people out, so we can keep going, so we can keep helping the people who need it the most.So anyway, that’s it. Awesome. Well, guys, thanks for tuning in, and everybody, have a wonderful rest of your week. Tannetje, thank you so much for being here. You can follow Dr. Tannetje Crocker on Instagram, and TikTok, and anywhere else I should mention?

Dr. Tannetje Crocker:
I’m on Facebook, kind of. You’re the king of Facebook.

Dr. Andy Roark:
Kind of. Yeah, no, I got the whole Facebook thing just staked down. It’s just-

Dr. Tannetje Crocker:
Yeah. Yeah. There’s no room for any of us.

Dr. Andy Roark:
… yeah, you have to come through my neighborhood. Nope, no room for anybody else there. All right, guys. Take it easy, everybody, and that’s what we got for you guys. I hope you enjoyed it. I hope you got something out of it. As always, if you did, you can leave me a nice review wherever you get your podcasts. If you’re watching this on YouTube, hit that Like and Subscribe button. Gang, take care of yourselves. Be well. Be kind to each other. See you next week. Bye.

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

Domestic Violence, Veterinary Medicine and the Purple Leash Project

October 14, 2022 by Andy Roark DVM MS

Dr. Traci Zager joins the podcast to talk about the role pets can play in domestic violence and keeping people in dangerous places. She discusses how animal abuse and domestic abuse are often linked, the Purple Leash Project and how initiatives like these can aid people seeking shelter from domestic violence. She talks about what every veterinary professional should know, and how we can use our knowledge and skills to make a difference in our own communities.

Cone Of Shame Veterinary Podcast · COS – 166 – Domestic Violence, Veterinary Medicine And The Purple Leash Project
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This episode has been made possible ad-free by Purina Pro Plan Veterinary Diets!

LINKS

The Purple Leash Project: https://redrover.org/the-purple-leash-project/

Red Rover: https://redrover.org/

OVMA Education Resources (Animal Abuse): https://www.ohiovma.org/veterinarians/resources/abuse.html

Safe Place For Pets: https://www.safeplacepets.org/

National Link Coalition: https://nationallinkcoalition.org/

Domestic Violence Hotline: 800-799-7233

ABOUT OUR GUEST

Dr. Traci Zager received her B.S. in Biology with Chemistry minor from California University of Pennsylvania. She then completed her MBA from Youngstown State University and her Doctorate of Veterinary Medicine from The Ohio State University. After graduation, she worked as a small animal and exotics veterinarian in Northeast Ohio before joining Nestlé Purina PetCare as a full time Veterinary Communications Manager in 2021.

In addition to small animal medicine and nutrition, Traci has special interests in companion animal behavior and education. She currently teaches courses online to veterinary technician students at her Alma Mater CalU of PA, as well as continuing to practice small animal/exotics medicine on the weekend.

Dr. Zager also served on the Animal Abuse Reporting Taskforce for the Ohio VMA, which helped to create educational materials on abuse reporting for Ohio Veterinarians. This taskforce was so important because legislation was recently passed to make Ohio a mandatory reporting state for all veterinarians. Dr. Zager also occasionally helps her local AWL with abuse cases.

Fun fact: Dr. Traci Zager is a new mom of a beautiful little boy named Jameson Henry Zager!


EPISODE TRANSCRIPT

Dr. Andy Roark:
This episode is made possible by Purina Pro Plan veterinary diets. Welcome everybody to the Cone of Shame Veterinary podcast. I am your host, Dr. Andy Roark. Guys, I got a great episode today. Have a bit of a heavy episode today, I have to give out trigger warning. This is an episode about domestic violence and also it touches on animal abuse. And so we’re talking about the Purple Leash Project. We’re talking about fighting back and making a difference in ways that vet professionals can get involved. I’m very happy to have this conversation and I learned a lot in this conversation and it’s good.
It’s motivating me to take some action and to get more educated and to look at how I can support. But if domestic violence, if animal abuse are triggers for you, this might be an episode to skip or to check out the transcripts. We do have transcripts of our podcasts thanks to Banfield Vet Hospital. They made transcripts possible in an effort to help increase inclusivity and accessibility in our profession, which is a super awesome thing that they do. And we’ll have links to that in the show notes and over on the website. And yeah, that’s it. So guys, good episode coming up. I hope you’ll enjoy it. I got a lot out of it, I hope you all too. 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. Traci Zager. Thanks for being here.

Dr. Traci Zager:
Hi, thank you so much for having me. How are you today?

Dr. Andy Roark:
I’m good. I am good. I’m super good for a Monday. It’s been a wild day back in the office as you know, but man Fall is here, did the pumpkin patch thing with the kids over the weekend. You’ve got, you’re not there yet, but you’re going to be there. Tracy has, she has a five month old little boy, her first. Just back from maternity. The excitement is just coming. How is the walking going at your house?

Dr. Traci Zager:
Oh my gosh, he’s doing great. He’s running around in his little walker and chasing the dogs and we went apple picking. We went to an orchard recently and he got to help us pick some apples and sit around some pumpkins, which was fun. But yeah, he’s not quite old enough to pick his own pumpkin or apples yet, but we’ll get there.

Dr. Andy Roark:
But you got that Halloween baby pumpkin picture, didn’t you?

Dr. Traci Zager:
Oh, we’re going to, We got one with a pumpkin, but we haven’t gotten one with him in a pumpkin yet.

Dr. Andy Roark:
Oh yeah. The opportunities are endless. Good timing, good timing on that. Everyone should plan their pregnancy around photo ops, I think. And you just nailed it. Well done. Alright. For those who don’t know you, you are a veterinarian communication manager with Purina. You are a practicing veterinarian. You do small animal and exotic in Northeast Ohio. And you are here talking with me about the Purple Leash Project, which I am super pumped about. I’m really glad that you’re here. This is something I think more people should know about and I appreciate you making time to be here. So thanks a lot for that. Do you want to go ahead and kick us off and just give a mile high view on what the heck is the Purple Leash Project and why is it important?

Dr. Traci Zager:
Absolutely. So the Purple Leash Project is a partnership between Purina and Red Rover. Essentially what they do is they provide grants to domestic violence shelters to help them become pet friendly. The biggest problem that we know that a lot of these survivors face is that they have to make the choice of whether to stay in an abusive relationship to protect their pets or leave their pets behind and escape. And that’s not something that we want them to have to choose. We want them to be able to take their whole family with them. So we know also just how often this is happening that it’s just really important that we provide these grants and help these domestic violence shelters to become more pet friendly so they can take them with them.

Dr. Andy Roark:
Can you tell us a little bit about Red Rover? That’s a group that I only learned about through you and I don’t know if other people are really familiar. So tell me a little bit about that.

Dr. Traci Zager:
Yeah, so Red Rover is like a Red Cross for pets. They provide housing and relief for people and pets in crisis situations.

Dr. Andy Roark:
Tell me a little bit more about why having pet-friendly shelters is so important and the impact on survivors. So just you unpack it a little bit, but give me a clear picture of the prevalence of this and that reality.

Dr. Traci Zager:
Yeah, so one in three women and one in four men will experience domestic abuse or domestic violence at some point in their lives. And so with it being that prevalent, we also know how many people have pets and that’s a huge part of their life. It’s a huge part of their family and that human animal bond is just so important. And we know 48% of people that are trying to escape a situation like that, delay their escape in order to help escape with their pets. So we don’t want them to have to wait to get out of these situations. We want them to be able to get out as soon as possible. The other thing is we know a lot of abusers will threaten their pets or even threaten to kill their pets if they try to leave. So having a way for them to escape and know that their pet is safe as well is going to help them recover and help their mental health as well. If they’re worried about what’s going on with their pet and their abuser as they try to escape, they’re never going to be fully free.

Dr. Andy Roark:
Okay. Can you tell me a little bit about where the veterinarian starts to interface with this? So let’s talk, I hate to go too much here, but I think it’s important, let’s talk a bit about animal abuse as it relates to domestic abuse, and then start to unpack what is the role of the veterinarian here? What should we be looking out for in our practices? How do we start to perceive these situations?

Dr. Traci Zager:
Yeah. So the role of the veterinarian is way more than I think a lot of us consider on a day to day basis. So the link between domestic violence, elder abuse, child abuse, it’s just so prevalent, and it’s part of that cycle of violence that we think about so frequently. If one population of vulnerable individuals like pets are likely to be harmed by an abuser, then other vulnerable populations are likely to be abused as well. So we think of domestic violence and we think of child a abuse and neglect as well. And we also know just how often when things are being investigated, another type of abuse or violence is uncovered.
So on the National Link Coalition’s website, they detail a statistic that I find just really powerful. So in an investigation of homes that were suspected of child abuse, they range between 60 and 88% of those homes also having animal abuse found. And so it’s happening as a coincidence really commonly. And we as veterinarians, if we’ve always been mandatory reporters of child abuse and domestic violence, that’s always been a thing. But not every state has some sort of legislature or laws around being a mandatory reporter for animal abuse, which I find crazy. And so when we report a suspected animal abuse, we may be saving other vulnerable populations within that household. We might be leading investigators to find child abuse or domestic violence and helping to save those individuals as well.

Dr. Andy Roark:
Yeah, we have a broad swath of people in the vet profession that listen to the podcast and everything. So just to run to this quickly, what are telltale signs? What are the flags that we’re looking for where we may be potentially looking at animal abuse? Can you run me through those?

Dr. Traci Zager:
Absolutely. So there’s a range of different types of abuse that you could see, whether that’s neglect or hoarding, intentional abuse or non-accidental injury or organized abuse, which is things like animal fighting. The biggest red flags I would say, I have seen in practice is when the injuries don’t match up to the history. So if an animal is hit by a car, they’re not going to have bilateral rib fractures and a hind limb that’s potentially fractured in multiple places. They’re not going to have fractures that are healing in different or in different states of healing. So looking at all of those red flags, when the history of what they’re saying happened and what the injury pattern you’re seeing is, they’re not matching up, those are the biggest ones that I would say.

Dr. Andy Roark:
Walk me out of this situation. So you’ve given me this place and let’s just say that I’ve got a pet in and a history of injuries. And they go, “Gosh, this pet seems accident prone.” And I’m looking at him going, “These stories don’t match up.” And I thought your fractures at different stages of healing. That makes a lot of sense. I can imagine me being in this room and not wanting to believe what I’m looking at, can you help me get my head around of steps that I might take from there? We started to talk about reporting it and honest to say I’m not exactly sure where I would report it. Can you help me parse out where I would go from here?

Dr. Traci Zager:
Yeah, absolutely. And this is where I really got into this space and how I became so passionate about it is because I was in your situation. I was in the room with a client and things weren’t adding up and I needed to figure out what to do next. And I felt like there were just, I didn’t know where to look. I didn’t know what resources were out there and I didn’t know who to ask. We’re all afraid that we’re wrong, we’re veterinarians. We’re really, really good at being right and we really don’t want to be wrong about something so serious. And so a lot of people that I talked to as I was working through this, didn’t want to make reports or didn’t want to ask those tough questions in the room because they didn’t want to suffer the embarrassment or the potential consequences of being wrong about that or being wrong in that thinking.
So I think if you’re noticing anything, you are the one who’s most qualified to make that determination of whether or not the history and what you’re finding on your physical exam is matching up. Police don’t know how to do that as well. Lawyers don’t know how to do that. Veterinarians are really on the front line of trying to figure out, is this a non-accidental injury? Is this abuse or is it not? And I think that’s the first step in this thinking is realizing that you’re the expert as a veterinarian or a veterinary technician. You’re the one who understands how these injuries happen and you’re the one who knows what to look for on an exam. In those instances where maybe you’re not sure, this is where it’s a really good idea to have that relationship with these reporting organizations before you ever need to make a report.
So you want to feel comfortable enough to call and say, “Hey, maybe I’m not a hundred percent sure, but this is what I’m seeing. What should I do next? And how can I help you in the steps going forward?” And they are more than happy to help you with that. So you don’t have to be a hundred percent right, you don’t have to be a hundred percent sure, but if you think it’s happening, you should make a report if you have any sort of reason, reasonable suspicion. And those reporting partners vary based on where you live. And the National Link Coalition’s website has a directory based on your county. So you can look up exactly who to report to. They’ll give you the organization’s name and phone number, maybe even their email and their address on that website. So you can write that information down and have it available to you before you ever need it.
And I would really recommend to any veterinarians listening, make those relationships now. Call them, tell them that this is what you’re thinking about, that you’re not a hundred percent sure about what to do. But you do want to reach out and have those relationships so that if you’re not sure you still feel comfortable calling and talking to someone. Because what happens after you make the report, you’re not the police, you’re not the lawyer, you’re not doing anything else. You’re just giving them your opinion and stating that you think something might be happening. You’re giving them your objective exam findings and what happens after that is totally not up to you. You don’t have to worry about all that.

Dr. Andy Roark:
This is really helpful and I totally hear what you’re saying about going and having those relationships. So, for me right now, say I’m not looking at anything particularly that I’m concerned about, but I see what you’re saying and I go, “I don’t have those relationships.” So I’m going to put the link to the National Link Coalition down in the show notes. It’s definitely something, I’m going to just take a look at to have that information.
Do we as doctors, reach out to groups now and say, “I’m not looking at anything. I just wanted to say hi and introduce myself.” Is that what we have in mind or are you more, When you say have a relationship, do you mean mostly know who you would contact if and when you needed to? If we are reaching out now, what am I saying? Because I don’t want this to be awkward, but in the same way, I think this is important. And so I’m really navigating this weirdness of I couldn’t live with myself if I didn’t say something and someone was negativity affected. And so I’m going to push myself to go ahead and get my ducks in a road just so I can be there if someone ever needs me.

Dr. Traci Zager:
Yeah, I think both. So it’s okay if it’s awkward. It doesn’t have to be, but it’s okay if it is, to just reach out and say hi and just say, “Hey, I’m a local veterinarian. I was just doing some research on the connection between animal abuse and domestic violence and child abuse. I think it’s really important that I just reach out and say hello. And that way we can get to know each other a little bit.” I think it’s also really helpful, they can potentially educate your clinic. So depending on the organization you’re reaching out to, they deal with this more than you do. They might be able to come in and say, “Hey, let’s do a 30 minute talk where I tell you more about how to investigate these things and determine whether or not you do have something going on in your clinic or what to look for, or I can just meet with you for lunch and we can feel more comfortable talking to each other and know what we’re looking for on both ends.”

Dr. Andy Roark:
Yeah, that makes a lot of sense. What happens, Tracy, when you call these places? I imagine me putting in this phone call going, “I don’t really know.” And then there’s helicopters and people crashing through windows and things like that. I know that’s not, but what should my expectation be if I reach out to a group or support network and say, “Hey, I’m looking at this, but I don’t really know.” What is that set in motion?

Dr. Traci Zager:
Yeah, so they might ask you for your exam findings. So they might just say, “Can you just let me know what you found on your exam? Give me some objectives, some objective information that I can look through and help you to determine if there’s something going on.” They might say, let’s say if it’s a hoarding case. So I had a hoarding situation with one of my clients where I determined that that was what was going on, and all I did was help her find resources and help. So as soon as I contacted our local anal welfare league, it’s not like they came out with handcuffs and put her in the back of a squad car. So they sent somebody to the house, they helped her rehome a lot of these animals. They helped her get the animals out and find new homes and get veterinary care.
They educated her. It wasn’t a situation where she ended up going to jail. They just provided her with the resources she needed to get out of this situation. And 90% of the time that’s what happens. So there’s education, there’s some sort of intervention where the pet is helped, the owner is helped. They want these pets to stay with their owners. So if it’s a neglect or they didn’t know better type of a situation, they educate them, they help them remediate the situation, and then they move on and continue with just welfare checks on that animal.
If it’s a really bad situation like we’re concerned about a non-accidental injury or intentional abuse, they might do a welfare check. They might also consider bringing police along, things like that, just to see what’s going on in the house. They might investigate if there’s been any reports of things like domestic violence or child abuse in that home before they do that welfare check. And again, after that, after the veterinarian has made the report, nine times out of 10, they don’t need anything else from you. You make your report, you get concerned. You might be able to call and ask what happened later on, but you don’t have to be involved in anything else after that.

Dr. Andy Roark:
Okay. That makes sense. And you’re clearly really passionate about this, and this is something that I know that you were really interested in before you went to Purina. How did Purina decide to get involved in the Purple Leash and how did that get started?

Dr. Traci Zager:
Yeah. So I know that there was, I don’t know a hundred percent sure, Andy, how it first started at the very beginning, I do know that the partnership between Purina and Red Rover started in 2019, and that was really when the whole grants and all of that started. I do know as well that in general, Purina got started in this space because we really care about the human animal bond. We care about keeping pets and people together. And this is one of those situations where people are having to make really, really difficult decisions to leave their pets behind in scary situations, and we don’t want them to have to make that choice.

Dr. Andy Roark:
That makes total sense. Talk to me a little bit about how veterinarians and the public can support Purple Leash. How do they engage in what happens?

Dr. Traci Zager:
Yeah, so the most obvious way that veterinarians could be a participant in Purple Leash Project is to make a donation. So on the website, you can make a donation and they’ll send you one of these beautiful purples leashes. They have really nice cushy hand grips, and they’re very nice leashes, but they have walk heel together on them, which is really cute. It really symbolizes that bond. And the purple is obviously a nod to domestic violence awareness, which is the purple ribbon.

Dr. Andy Roark:
Yeah, I love it. What else should people know about Purple Leash Project, Red Rover any final words, anything like that? This has been super helpful and insightful. I really appreciate you talking through with me. So but Final Pearls.

Dr. Traci Zager:
Yeah, so I think one of the biggest one really is that the goal for the Purple Leash Project is to make 25% of domestic violence shelters pet friendly by 2025. So that’s our big goal. That’s what our we’re striving for as far as the Purple Leash Project goes. And then as far as the veterinarian’s role in all of this, just know that by listening to this podcast and by going into your exam rooms with this in the back of your mind and seeing your clients and their relationships with each other and their pets through this lens, that’s really half the battle, is being willing to think about it, being willing to educate yourself about it, and then putting it into practice when you go in and do your exams.

Dr. Andy Roark:
Oh, Tracy Geiger, thank you so much for being here. Thanks for the work that you do. Thanks for telling me about it, guys. Thanks for listening today. I’m going to put links to all of these resources to Purple Leash Project, to the National Link Coalition, to Red Rover, all those sorts and stuff. I’ll hook you guys up in the show notes. Okay and take care of yourselves, be well, do good work alright, see you later. And that is our episode, guys. I hope you enjoyed it. I hope you got something out of it. As always, it feels good to make a difference. Share these links. Think about getting involved and helping out. And I’m going to do the same, but guys, yeah, sometimes we forget how lucky we are and we forget what other people are facing. And most times we don’t have any idea what’s going on in the houses of the people and the pets that we take care of and stuff. Anyway, gang, be well. Take care of yourselves. I’ll talk to you later.

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

6 M’s of Treating any Behavior Disorder in Practice

October 12, 2022 by Andy Roark DVM MS

Dr. Amy Pike joins the podcast to discuss behavior screening in general practice! Dr. Pike was recommended by multiple listeners to the podcast because of her lecture The 6 M’s of Treating and Behavior Disorder in Practice. One listener even said the lecture helped their practice become better equipped to handle or rear behavior cases!

The 6 M’s are:

1) Medical Rule Out

2) Mental Enrichment

3) Management

4) Modification of behavior

5 Medications and Products

6) Monitor and Modify the Plan

Cone Of Shame Veterinary Podcast · COS – 165 – 6 M’s Of Treating Any Behavior Disorder In Practice

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

LINKS

Links to Amazon.com are affiliate links and help support the show. (They’re also much smaller than normal links and easier to copy when typing up show notes!)

Kong Products: https://www.kongcompany.com/

Doc & Phoebe’s Indoor Hunting Cat Feeder: https://amzn.to/3R9Dnr2

Blackwell’s Five-Minute Veterinary Consult Clinical Companion: Canine and Feline Behavior – https://amzn.to/3R6Vhuj

Decoding Your Cat: https://amzn.to/3wrD4Qe

Decoding Your Dog: https://amzn.to/3pKVA2p

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/on-demand-staff-training/

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Pike is a native Arizonan and graduated from Colorado State University’s school of veterinary medicine in 2003. Working as an Army veterinarian after graduation and taking care of the Military Working Dogs returning from deployment spurred her interests in behavior medicine. Dr. Pike completed a Residency program and became board certified in 2015. She is owner of the Animal Behavior Wellness Center and was recently named one of the “Top Veterinarians of Northern Virginia” by NoVa Magazine for the sixth year in a row.

Dr. Pike speaks all over the world about veterinary behavior medicine, she has been published in numerous veterinary journals, she has conducted and published two scientific research studies, and is a contributing author in five clinical text books. She mentors 4 clinical behavior residents and is a clinical instructor for E-training for dogs and the Masters Program in Applied Animal Behavior at Virginia Tech. She is an advisory board member for Royal Canin, Fear Free, and the Animal Welfare League of Arlington, and is a consultant for Chewy, Inc. In her (fairly non-existent) spare time, she enjoys gardening and hanging out with her active-duty Army husband of 20 years, their 14 yr old daughter, and 9 yr old son, and their menagerie- Dobby (6 yr old Devon Rex), Ike (4 yr old Giant Schnauzer), Scooby (2 yr old, Mini schnauzer), Ginny (10 month old Airedale), Prickles (1 yr old Hedge Hog) and Pavlov (16 week old Indian Ringneck Parakeet).


EPISODE TRANSCRIPT

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

Dr. Andy Roark:
Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great episode today for anybody in the vet practice and, honestly, it’s probably pretty great for pet owners, who are interested in behavior, to hear as well. Gang, Dr. Amy Pike is here talking about the 6 M’s that she uses to treat any behavior disorder in practice. And guys, this is so packed full of pearls. It’s like a pearl bag that’s one size too small for all the pearls. That’s what it’s like, it is. This is a great one. It’s short and to the point. It’s about 25 minutes of our interview. Man, you’re going to get something out of this. I can’t wait for you to hear it. Let’s get into this episode.

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

Dr. Andy Roark:
Welcome Dr. Amy Pike. Thanks for being here.

Dr. Amy Pike:
Yeah, thanks for having me. I appreciate it.

Dr. Andy Roark:
Oh man, it is an honor to have you here. You are here because I asked the world on social media, “What is the best lecture that you have seen as a veterinary professional? Who’s the person who gave a lecture that really you thought was amazing? And what did they talk about?” And you got one of the nods, a significant nod. The feedback was something along the lines of, “Dr. Amy Pike’s lecture helped me change the way that I screen behavior cases and how we treat these pets. And it made a big difference in our hospital.” And I thought, “Man.” No pressure, Amy. Holy moly.

Dr. Amy Pike:
I know, right. I know. Can I retire now?

Dr. Andy Roark:
Yes, you should be-

Dr. Amy Pike:
Is that it, I’m at the pinnacle?

Dr. Andy Roark:
Just drop the veterinary mike and take the rest of the night off because you crushed it. You are, for people who don’t know you, you are a boarded veterinary behaviorist. You have worked as an army veterinarian, and you worked with military working dogs. You have been named one of the top veterinarians of Northern Virginia by Nova Magazine for six years in a row. You actually own your own hospital, correct? The Animal Behavior Wellness Center. And that is in Northern Virginia.

Dr. Amy Pike:
Yeah, we have two locations, one in Northern Virginia, one in Central in Richmond.

Dr. Andy Roark:
Oh, very nice. And then you have residents of your own now, is that true?

Dr. Amy Pike:
We do, I have little minions, four of them.

Dr. Andy Roark:
You’re taking over this profession. I love it. Well, thank you so much for being here. I just wanted to come in… So that was the guidance that I got was, “You got to talk to Amy Pike about the way that she screens behavior in these animals.” And so I don’t have a specific case that I want to put on you, but help me get into that headspace. Yeah, walk me through, how should I be looking at this in practice, Amy?

Dr. Amy Pike:
Yeah, so I went to Colorado State. And any of you who have seen Mike Lappin lecture, he was one of my professors. And he likes to bring things into these little algorithms of, “If this, then that,” kind of thing. And that’s really where I wanted to come at this from, because not every clinician has an interest in behavior. Nor have they had any behavior, potentially, even in school, or in continuing education. And so any behavior case, no matter whether it be the worst aggression you’ve ever seen, or a puppy that’s peeing in the house and hasn’t been potty trained, how do you just start from the beginning and work through any case? And that’s where I came at this from.

Dr. Andy Roark:
All right, let’s do it. Run me through your Mike Lappin style algorithm. I’m fired up now.

Dr. Amy Pike:
Yeah, so I call it the 6 M’s. So the first M would be medical rule outs. So behavior is very much a rule out diagnosis. So that’s why any behavior case should come to see their veterinarian first and foremost. Because that little puppy peeing in the house, maybe it’s not house soiling because it is not yet house trained, it’s got a urinary tract infection. So we want to make sure that we rule out any sort of medical concern. And that, of course, includes doing our medical due diligence as veterinarians, doing your full physical exam. Orthopedic, neurologic, especially because pain can be a huge contribution to behavior concerns. And then CBC chemistry, urinalysis, and a thyroid panel. So that’s where I start with any behavior issue.

Dr. Andy Roark:
I love it. That is super commonsensical in a way, though I always struggle with. When you’re at a party and people are like, “Hey my cat’s peeing outside the box.” Let’s make sure this isn’t a medical issue is a great… “See you on Monday,” that’s how you answer that piece of advice. I love it.

Dr. Amy Pike:
Yeah, make an appointment with your vet.

Dr. Andy Roark:
Yeah. Thanks. Oh, I love it. All right, great. So I’m 100% on board with the first one. First M is medical rule up. Okay, what’s number two?

Dr. Amy Pike:
Yeah, so second M can be… Well, I interchange the next two. So we’ll go with mental enrichment. So mental enrichment is all about stimulating a brain, basically. And so we want to make sure that these pets have enough opportunities to do their normal behavioral repertoires. So cats love to hunt, so we want to make sure that cats have the ability to be able to hunt, to climb vertical spaces, to get away from other cats in their territory.

Dr. Amy Pike:
We want to make sure that dogs, especially dogs of working lines and working breeds have enough stimulation that they’re going to be tired. And I hear trainers all the time say, “Oh, you need to exercise that dog. Oh, you need to exercise them. Exercise is like the end all, be all.” But, let’s say, you have a dog that has leash reactivity and it can’t handle seeing other dogs on leash. Well, exercise is not going to be good for that dog. Taking it out on a leash walk, where it’s exposed to all of its triggers, is not going to be any good. So how do the owners go about actually tiring that pet out? And the easiest way is just through mental stimulation. You can do trick training. You can do nose work, where you hide pieces of treats all throughout the house and they have to find it. If you’ve ever seen a puppy after puppy class, they are exhausted. But they romp and play with their friend for 45 minutes, and they’re not necessarily tired after that. They’re raring to go for another round. So you have to stimulate that brain.

Dr. Andy Roark:
That’s awesome. So hold on, I’m going to be honest here and say you blew my mind. Which, again, it seems super simple when you say it. And I’m like, “I have always been one of those exercise, exercise veterinarians.” Just because a tired dog is a good dog. I see understimulation as a problem in a lot of pets that I see. Anyway, and I am that person too. I am that person who’s like, “If I don’t get out and exercise, I start getting stir crazy.”

Dr. Amy Pike:
But if you think about it, Andy, from your perspective, if you go out and, let’s say, go for a run. You’re training your body to be a better runner. So if we take that border collie out for a run, they’re just going to be a better runner. They’re going to need more and more and more and more. And so, really, that’s a self-licking ice cream cone, so to speak. We actually need to tire that brain out a little bit better.

Dr. Andy Roark:
Well, I really like this a lot, and I want to unpack this. Because you’re right, I have literally had clients who are like, “I took him and then I started exercising and walking and running. And that was great for a couple weeks. And then he got in shape and, now, I’m in as much trouble as I was in before.” And so this is a new concept or idea for me. So give me some guidelines here about these mental workouts. What are you looking for? If a client says to me, “Yeah, first of all, I can’t out-exercise my husky. I break way before she does.” What kind of guidance do you have here? Help me get an idea in my head of how to do this and what guidance to give.

Dr. Amy Pike:
Yeah, it can be as just as easy as not feeding the dog out of a bowl, or a cat. So make them work for that food. Put it in puzzle toys, hide it. We call these adventure boxes. We take all the Amazon boxes and put kibble inside of one. And then put another one in there, put some toilet paper or paper towels, put some more kibble in there. So the dog actually has to go through that. So rather than your Labrador taking 0.2 seconds to hoover up its food, maybe it’ll take 10 to 20 minutes. And that 10 to 20 minutes is actually exhausting because they really have to think about it.

Dr. Amy Pike:
I, now, as a veterinarian, not when I was in general practice, but now as a veterinarian, I have very much a desk job. Because I can’t move for most of my patients because they will try and eat me, should I do make any sort of motion. But I’m exhausted at the end of the day. I haven’t done anything physical, it’s because my brain’s been working the whole time. So that’s one easy way. Even just 10 to 15 minutes of running through there, sit down, shake, touch, whatever tricks that they know, or teaching them a new trick, can be just as mentally stimulating. My kids love to hide the feeder toys for the cat all around the house. They fill these little mice up every night and they hide them all over the house. And the cat has to hunt all night. And it’s not up waking me up in the middle of the night saying, “When’s food coming?” But it’s actually getting some mental stimulation, and performing some of those normal behaviors that it would otherwise.

Dr. Andy Roark:
I love this. And I love your example of the Amazon boxes and things like that. I’m 100% running through, in my mind, how to put this together. Are there toys that you like specifically for dogs and cats? Are there certain brands that you’re like, “Yeah, that’s what I recommend,” or things like that to help get people started?

Dr. Amy Pike:
Yeah, there are so many your head would spin. There’s some really good enrichment social media Facebook groups out there. But one of my favorites for cats is the Doc & Phoebe’s mice. Those are what my cats love to find. And then, really, for dogs, I do a lot of DIY for dogs. Because I have pretty destructive dogs so I’m going to make something that they can destroy. But they are a lot of good… KONG makes a bunch, not even just your normal KONG that you stuff, but the one that has a little hole in the side. I think it’s called the KONG Wobbler, where you can manipulate it and topple that food out.

Dr. Andy Roark:
So I’m a big KONG guy. I looked over to the side, I used to have a shelf of KONG, this kind of display. But my Goldendoodle has just been helping himself for the last couple of months. And by the time I find it, it’s too late.

Dr. Amy Pike:
He’s like, “Hey, I need enrichment, Dad.”

Dr. Andy Roark:
Oh, he’s smart. He waits for me to leave, and then he just helps himself. But my nephew, who’s 2-years-old, came to visit a little while ago. And he found those big KONG Wobblers, and there was two of them. And that kid just toddled through the house, holding these two KONG Wobblers that were as big as him. It was absolutely awesome. So anyway, all right, cool. I’ll stick some links in the show notes, at least for KONG stuff and for the Doc & Phoebe. All right, cool. So we’ve got medical rule out, we got mental enrichment, where are we going from here?

Dr. Amy Pike:
The third one’s going to be management. So management is just like staunching the bleeding, wait, put a tourniquet on, or put a bandage on something. Maybe we don’t have time to explore that wound a little further, but we need to stop that bleeding immediately. So management is what’s going to do that for behavior. So we are going to try and avoid the triggers, so whatever that trigger may be. So, let’s say, the dog is leash reactive to other dogs. All right, we’re going to avoid leash walks as much as possible. Or we’re going to take the dog to a remote trail. Or, during COVID, it was nice because the schools were empty, people could go to the school grounds and walk around. Church parking lots are a really good place. Business centers that are empty and void of employees right now also make great areas. So that’s just going to prevent the practice of that problematic behavior.

Dr. Amy Pike:
So number one, we know practice makes perfect. So if we stop the practice of that behavior, the dog’s not going to get any sort of reinforcement or punishment for it. But it will allow us then to be able to train something in the future, which we’ll talk about. But the other thing too is, especially with aggression, because that’s the number one thing that I see as a behaviorist, it’s going to keep everybody safe. And if we can keep everyone safe, then we can keep that pet in the home until we’re able to implement treatment. Because behavior treatment isn’t an overnight thing. I know owners obviously come in and they want the magic wand, but it doesn’t happen. And it’s going to take some time. So we are going to have to implement management in the meantime.

Dr. Andy Roark:
That totally makes sense. So, basically, what I’m hearing when you say management is, let’s not let these problems detonate. And just put ourselves in a safe place while we work on the mechanism behind the scenes. Is that pretty accurate?

Dr. Amy Pike:
Exactly, yeah.

Dr. Andy Roark:
Okay, cool. Great, I like that. What does that look like in things like house soiling in cats or things like that? I see that in dogs, and I think dog triggers seem to be much more known and recognized. And cat triggers, I’m not saying they’re not there, I’m saying pet owners often don’t see them or get them. And then I get a lot of, “I don’t know why he’s doing this.” Help me with that.

Dr. Amy Pike:
Yeah, so one of the things, obviously, the owner’s going to want to stop the urination or defecation on their carpet. So if we maybe just confine that cat to a bathroom with its own litter box; food; and water, or a basement maybe that’s unfinished. Somewhere where, even if the behavior happens, it’s not going to be as detrimental to the oriental rug or something like that. But also, inner cat aggression is a big component, whether it be obvious or subtle, in a multi cat household. So separating all the cats until we figure out what the root cause is for the elimination. But that would be one other way that we can go about that.

Dr. Andy Roark:
That’s awesome. Okay, that totally makes sense. Great, I’m on board with management. Where are we going from here?

Dr. Amy Pike:
Excellent. So the next one would be modification of behavior. So this is teaching either the animal an alternate behavior to the one that we don’t want. Let’s say, dog is jumping on guests. All right, we’re going to teach it to sit down for attention instead. Or if we’re talking about something that is fear, anxiety, or stress related, we’re going to desensitize them and counter condition them to that trigger. So this is all the training aspect of what I do. I equate it to the therapy in humans. It’s like you have to put in the work. And this is the work that’s going to take the time in order to teach those different behaviors.

Dr. Andy Roark:
Perfect. I’m making copious notes over here. This is really good, yeah. All right, that’s wonderful.

Dr. Andy Roark:
Guys, I just got to jump in here real fast and give a quick shout out to Banfield the Pet Hospital. Guys, we have transcripts for this podcast. That’s right, at drandyroark.com you can find transcripts to all of the Cone of Shame Veterinary Podcast episodes. Banfield has sponsored that, they have made it possible to increase accessibility and inclusivity in our profession. I’m so grateful to them for that. We could not do it without them. Gang, I hope you’ll take advantage of this resource. Feel free to check it out. It’s not hard to find. We try to make it super easy to find. Anyway, I just got to say thanks to those guys. And I want you guys to know that those transcripts are there, if you need them. Gang, let’s get back into this episode.

Dr. Andy Roark:
Is there anything that we need to set… Help me, when we start talking about modification of behavior, what expectations do you try to put into the mind of the pet owner? Because this is a lot of work. It’s easy to be like, “We’re just going to alternate your dog’s behavior so he doesn’t jump up on people when they come to the house.” And they’re like, “Great, that sounds like a busy day.” And it’s like, “Oh no, no. Oh, no.” Help me with that. How do you do that?

Dr. Amy Pike:
Well, and I always tell people too, I’m obviously busy, I have a family practice and everything. And so if management can solve a lot of your issues, let’s say, it is this jumping dog. And you just say, “Hey, I’m going to just put the dog away when I let people in and then it can’t jump on people.” If that’s all you want to do, that’s fine. I am totally cool with that.

Dr. Amy Pike:
But if you do want to do the modification of the behavior, then we are going to have to train that. It’s going to take consistency. It’s going to take using positive reinforcement based training. So making sure we reward that pet for that alternate behavior. And really, honestly, even if it’s something as simple as jumping up, we could probably teach that in one session. But getting the consistency under our belts is going to be the key. And that may take weeks to months, depending on how long this animal has been doing this behavior. If this has been seven years running and, now, we’re trying to change it, it’s going to take a little bit longer. Because there’s a lot of reinforcement history there. But if this is a new puppy, that’s going to be simple.

Dr. Andy Roark:
Okay, I like that. That makes sense. I’m totally on board with this. I love the way this program is coming together. So number five?

Dr. Amy Pike:
Yeah. So number five would be medication and products. And that’s if it is something that’s fear, anxiety, and stress related. So the house soiling puppy that we’ve ruled out medical, that is just a puppy that has never had potty training before, that’s not going to need medication and products. So I’m talking about dogs and cats with anxiety disorders. And so this can be anything from our nutraceuticals like ANXITANE and Zylkene. Am I allowed to say brand names?

Dr. Andy Roark:
Yeah, absolutely. Yeah, you can definitely, yeah. Yeah, totally. Yep. No, no, you’re all good.

Dr. Amy Pike:
Good. And then we can use the pheromones, like ADAPTIL and FELIWAY, all the way up to our psychotropic medications. And we have a few that are FDA approved in dogs. We’ve got Reconcile and Clomicalm, which are FDA approved for separation anxiety in dogs. We’ve got SILEO gel, which is approved for noise and storm phobias. We’ve got Enalapril, which can be hard to find, but it is approved for cognitive dysfunction in dogs. And hopefully in the next year or so we will get Pexion, which is a benzodiazepine that is approved for noise phobias as well. But other than that, we’re using everything off label in our veterinary patients. And we use all of the same psychotropic medication that they do in human medicine now. So we have lots and lots of options moving forward.

Dr. Andy Roark:
Talk to me about the timing of this. So when we’re laying out this program, number four modification of behavior, comes before number five, which is medication. Is that how it goes in practice? So I know there’s some difference here in behaviorists and how they do it. I’m really interested in this of when do I introduce medication? I think I’ve been guilty, earlier in my career, of sitting on medication too long when, had I introduced it earlier on with the training, I could have been more successful. And so I’m still parsing that. Can you comment a little bit on the timing of those things together?

Dr. Amy Pike:
Absolutely. That can be a little bit tricky. So the reason that I have it in this order in my talk is because there are some behaviors that aren’t going to need medication and products. And so, of course, I didn’t want to put that first. But for the cases that typically see me, I’m not seeing the jumping dog at the door, because I’m seeing the aggressive dog at the door. And for the most part, if the animal cannot be kept under a threshold, meaning the owners can’t manage the environment appropriately… Maybe they live in an apartment and the dog has to go outside to potty, and they’re leash reactive to every dog. Or they’re reactive to strangers, and they also live in an apartment and have to take the elevator 13 floors with other people, I am likely going to have to need some sort of medication in order to keep that animal under threshold.

Dr. Amy Pike:
Because nobody can learn when they’re highly aroused. So if you are stressed, learning doesn’t take place. And if the animal is reacting, nothing is happening between those ears except fight or flight. And so we need to make sure that those medications get on board, sooner rather than later, because, otherwise, they’re just going to spin their wheels with training and get frustrated.

Dr. Andy Roark:
Okay. All right. Can I ask you about a specific case that this could have come together?

Dr. Amy Pike:
Yeah, of course.

Dr. Andy Roark:
Okay, so this is interesting, and it’s a case that bothered me a lot because I didn’t feel like I had good tools in my toolbox to deal with it. Or maybe I didn’t process it, at the time. Because you’re in the exam room, the person’s laying out… I had a case… It’s been some time ago now, so I feel comfortable telling you about it. But, basically, it was a person who had an 11-month-old German shepherd in an apartment complex. And the dog was barking continuously and the neighbors were complaining. And I talked about exercising the dog a lot, which I think is true. Can you talk to me a little bit about that? And, of course, the owner said, she said, “I want medications for this dog.” And I did not like that. But now that I’m listening to you, I’m going, “Well, is this dog hyper stimulated because it’s being crated. And how do you train this dog that’s having this reaction?” Anyway, yeah, help me just process that, as I think back.

Dr. Amy Pike:
Yeah, I think the trouble with barking is they’re going to have to take a little bit deeper detailed history because barking has so many motivations. But, regardless, if it is pretty much all daytime hours, there’s probably a some sort of noise stimulus. That they’re hearing other things outside. Potentially, separation anxiety. And like you said, if we are unable… If that dog cannot even focus on owner trying to give it a treat when it’s quiet, and it just continually is barking, it is going to need medication.

Dr. Andy Roark:
Okay, that helps.

Dr. Amy Pike:
Now, of course, I’m going to do management, mental enrichment, all that stuff at the same time. As I tell my owners, it’s never medication in a vacuum. But the medication is going to allow us to be able to proceed in a much better fashion, and much faster.

Dr. Andy Roark:
Well, I come out of this interview thinking about that case. And thinking about mental enrichment is definitely the tool that I wish I’d had handy in my pocket, that I could have brought in as well as the exercise stuff that I talked about. Because that dog does need exercise. But that was maybe another thing. So anyway, that’s super helpful for me. I’m sure I’m not the only one who’s listening to this, who’s running back through their own cases and going, “I could have taken that one a different way.” Anyway, well, that’s why we do these. All right, perfect. And then that brings us to number six, what have you got?

Dr. Amy Pike:
Yeah. And number six is monitor and modify the plan. Because there is no behavior plan that goes out the door that’s perfect, especially when it comes to medication and behavior modification. Well, actually, I should take that back. Every single one of these things. Because no matter what I give owners, they could come back to me and be like, “I can’t crate that dog. Number one, it’s panicked.” Okay, we’re going to have to work on crate training. Or, “I can’t hold the dog back when people are coming to the door because it then redirects and bites at me.” All right, well, that’s something we’re going to have to modify.

Dr. Amy Pike:
So no plan that goes out that door is going to be perfect from the get-go. And so it’s very, very key. Behavior cases are probably some of the most intense as far as follow up is concerned. Because we need to be in regular touch with these owners to make sure that they are on track, and that everything is proceeding as we want it to be. And certainly with medications. Yes, we pick medications based off of what clinical signs we’re seeing, what neurotransmitters we want to target, et cetera. But it’s up to that brain, ultimately, whether they respond to it or not. And so I can pick the greatest medication based on the textbook chapter. If that dog hasn’t read the textbook chapter, then I’m going to have to alter that.

Dr. Andy Roark:
That totally makes sense. Well, great, this is super helpful. I love these six steps. This has been really helpful. I’ve taken away a couple of real nuggets and pearls today, so I call that a huge win. I want to ask you something now that may seem a little bit off topic in the moment. But I’ve been sitting with this since about halfway through our conversation. You are about the most laid back animal behaviorist that I have ever talked to. As far as your ability to be like, “We’ll see what happens.” And when you say, “Hey, if you want to put your dog away, instead of the dog who jumps up, you just want to put him away, that’s fine.” And I’m like, “Wow.” Legitimately, I had people who are animal behaviorists who are like, “Nope, we’re going to fix this.” And you’re like, “Well, find what works.”

Dr. Amy Pike:
I’m a realist. I am very much a realist. And, again, I’m also a client, to a certain degree. I have pets. They’re not all perfect. Certainly, my children are not perfect. And so you have to roll with the punches. And if management is all you can handle, have at it. Management and mental enrichment, I’m good with you.

Dr. Andy Roark:
Well, so two things. Number one, you and I talked about our kids before we started recording. And so you have a 14 and 9-year-old. I have a 9 and 11-year-old… Or a 14 and 11-year-old. It changes your perspective a little bit about what’s really important. You’re like, “Look, just get through the day.” And so I love that.

Dr. Amy Pike:
Exactly, let’s get through the day.

Dr. Andy Roark:
Look, we’re all just holding it together. Just let’s make it work. But, anyway, I think it’s really refreshing. I think a lot of us, as veterinarians, feel like we’re not getting it right. Or we didn’t 100% fix this. Or we’re not fixing it as fast as we should. And I just want to tell you, I really like your perspective. And I think that you make me feel much more competent, with a more laid-back attitude of, “You know what? We’re going to work on this, and some of it’s not going to work. And we’re going to keep adjusting.” But, anyway, I’m struck by that, talking to you. I think it’s really awesome. Actually, let me ask you this real quick. Do you have favorite behavior resources out there? So if you’re a veterinarian or a technician and you’re like, “This is my jam.” Where do you send people to?

Dr. Amy Pike:
Yeah, even if it’s not your jam, if you want more resources just for clients, the Five-Minute Vet Consult, Canine and Feline behavior one, is one of my favorites. I give it to all my students when they come on rotation. I love Decoding Your Cat and Decoding Your Dog by the American College of Veterinary Behaviorists. Might see a chapter in one of the books by yours truly. And those are great for clients too. I love being able to put those into puppy and kitten packs. If I were in general practice, that’s what I would do. I would put one of those books in every single one of my puppy and kitten packs and send those home with owners. Because that is going to be an invaluable resource for the life of that animal.

Dr. Andy Roark:
Those are great. I’ll put links to all that stuff in the show notes. Those are great books, Decoding Your Dog and Decoding Your Cat. And 100% written for pet owners as well. Really good call, really great recommendation. Amy, where can people find you online? Where can they learn more about your practice, things like that?

Dr. Amy Pike:
Yeah, well you can find me at our website at abwellnesscenter.com. And our Facebook page is the same AB Wellness Center. And we put lots of resources up there, lots of success stores from our patients, good ideas for management. We have a fun little post recently of a dog with his nice little bandana that says, “Don’t touch me,” so advertising his management to others. So we love that type of stuff.

Dr. Andy Roark:
I wish I had a bandana that said, “Don’t talk to me,” sometimes.

Dr. Amy Pike:
That’s what I said too. Yeah, leave. No hugs.

Dr. Andy Roark:
That’s so great, thank you. No hugs. Thank you so much for being here. You were really wonderful. Guys, everybody take care of yourselves. Thanks for listening. I will talk to you next week.

Dr. Andy Roark:
And that’s it, guys. That’s what we got. Thank you so much Dr. Amy Pike for being here. Gang, I love this. I love talking about this stuff. I love learning. I love getting better. If you want to get your team on board with episodes like this, just share it with them. It’s available on YouTube, if you have people who like to go and watch the podcast on YouTube. It’s wherever you get your podcasts. You can tell Amazon Alexa to play the latest Cone of Shame Veterinary Podcast and she’ll do it. And so you got that going for you. It’s easy to bring the team in.

Dr. Andy Roark:
Also, if you want to work with your team on making good recommendations and communicating more effectively with pet owners, I got you there too. You can head over to drandyroark.com and click on our store. And I have a course, which is my Exam Room Communication course for teams. It is my best advice and practices for training teams to work with pet owners. Check it out. Man, it’s my best resource that I could possibly make to help teams work better in the exam room. I hope that you’ll find something valuable in it. And that you and your team can get something out of it. I bet you can. Anyway, guys, take care of yourselves. Be well. I’ll talk to you soon.

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

Itty Bitty Kitty Anesthesia & Analgesia (HDYTT)

September 29, 2022 by Andy Roark DVM MS

Tasha McNerney CVT CVPP discusses best practices for anesthesia and pain control in a 0.8lb kitten. These cases are tricky and Tasha lays out why as well as what we can do to reduce the risk and decrease pain and discomfort of our patient.

Tasha and Andy talk through the importance of maintaining cardiac outflow, O2 therapy, blood glucose monitoring, and thermoregulation. Anticholinergics and fasting protocols are also discussed.

This is a FANTASTIC and short episode that is packed with clinical pearls. You won’t want to miss it!

Cone Of Shame Veterinary Podcast · COS – 163 – Itty Bitty Kitty Anesthesia & Analgesia (HDYTT)

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: http://www.veterinaryanesthesianerds.com/

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/store/

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

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

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

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

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


EPISODE TRANSCRIPT

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

Dr. Andy Roark:
Welcome, everybody, to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark, back with my good, good friend, the one and only Tasha McNerney. We are talking about anesthesia and analgesia in itty-bitty kitty cats today. This is super fun. It’s really interesting. I think a lot of us don’t think enough about these types of patients, but we certainly see them. What do you do for a cat that weighs less than one pound? Got you covered today. Guys, this is a great episode. 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 back to the podcast. My dear friend, the original anesthesia nerd, the one and only Tasha McNerney. Thanks for being here.

Tasha McNerney:
Thanks for having me again.

Dr. Andy Roark:
Always, always my pleasure. For those who don’t know you, you are a lot of things. You are a wonderful lecturer. You have been the vet tech lecturer of the year at the VMX conference before. I have met you at conferences. Actually, we met in Reno many years ago, and I’ve seen you speak a number of times. You and I have spoken together. We did a Hall & Oates themed track. They gave us a whole track to do something on vet med lessons from Hall & Oates, which I don’t know who signs off on these things, but-

Tasha McNerney:
I know. I don’t know how that got approved when I pitched it, but the fact that they were like, “Yeah, great,” my only regret is that we didn’t do the whole full-on costumes, of you as Oates, me as Hall, and-

Dr. Andy Roark:
I have fake mustache.

Tasha McNerney:
… it could’ve been so good.

Dr. Andy Roark:
I know.

Tasha McNerney:
Listen.

Dr. Andy Roark:
I have a mustache now I could’ve worn.

Tasha McNerney:
I mean, we might need to resurrect this.

Dr. Andy Roark:
Yeah. I agree. So, anyway, we have a history of highs and lows. We’ve made goofy internet videos together. But anyway, you are also a technician specialist in anesthesia, analgesia, and the founder of an enormous Facebook group called The Veterinary Anesthesia Nerds, which also has its own conferences now and things like that. It has really metastasized, if you will, and it’s a force of good in the world. You do great things. Anyway, you are my go-to for in the trenches, on the ground anesthesia, analgesia questions, and I’ve got one for you. Can I ask you about it?

Tasha McNerney:
Of course. Let’s do it.

Dr. Andy Roark:
Okay. This is a case that everybody’s seen, but I just had it. In all honesty, I just had it a week or two ago. So, I got this little black kitten. So, it was about .8 pounds, and it’s just a black domestic shorthair kitty cat, and someone had just found it beside the road, and they brought it in, and they said, “I would like to have this cat and to get it cleaned up and give it a home,” and I said, “I think that’s great, and I want to support that.” As I look at this cat, she has got a big swelling under her right mandible. So, on her neck there’s this big swelling, and I go and I look and there’s a draining tract, and as I squeeze around, I think that there is a cuterebra in there. There is some sort of parasite inside this draining tract. It’s not just infection.

Dr. Andy Roark:
So, I’ve got this itty-bitten kitten, true story, less than one pound, probably four weeks old, and I just am wondering to myself… I don’t want to ruin this cat, fear-free all the way, and it’s sort of like, I want to make sure that I’m keeping this little burger comfortable because this is going to hurt. There’s no way this doesn’t hurt, to have this thing pulled out of your neck, especially if I have to open the tract up a little bit to get to it. So, I just want you to go through with me… Tasha McNerney, talking about a cat this size, anesthesia, analgesia, how do you treat that? Give me some best practices. Help me make sure I’m doing a good job.

Tasha McNerney:
Yeah. So, there’s a lot of things. First off, right off the bat, what I would want to know with this kitten is, especially in the location that you’re telling me, is there any way that we have compromised the airway? We did have a kitten very similar to this come into a practice I relief at, and spoiler alert, you guys, this doesn’t have a great ending, but it had multiple cuterebra, and one of them in the neck area had migrated enough that it had caused a tracheal rupture, and euthanasia was chosen for that kitten just because surgical correction, even with surgical correction and a tracheal stent, might not be… So, again, that’s always going to be in the back of my mind. Has it compromised our airway in any way? If so, we still can work with it.

Dr. Andy Roark:
Thanks for giving me something new to worry about. That had never crossed my mind before, and now I’m like, oh, now I got that to worry about. Thank you for that.

Tasha McNerney:
Well, it’s vet med. There’s always something new to worry about.

Dr. Andy Roark:
Let me tell you something you never even considered that I’ve seen before. Oh, God. All right. Okay. No, I’m onboard.

Tasha McNerney:
All right. So, let’s say-

Dr. Andy Roark:
Note to self.

Tasha McNerney:
Note to self, just make sure that that trachea… Again, you don’t have to go through a full on let’s get a CT, again, unless you’re just feeling really ambitious, but other than that, if you feel like your airway and pulmonary-wise we are okay, all of anesthesia is preparation. I know that a lot of people think that anesthesia is kind of boring in the sense that a lot of these procedures were sitting and monitoring and just writing stuff down. There’s not a lot of movement, fast-paced action. Listen. All of anesthesia is just preparation to make sure that we don’t have fast-paced action once the animal gets onto the table. We want to make sure that we are planning as much as possible, and for a little kitten like this around for weeks old, around a pound in weight, this is really tiny, so we want to plan correctly, and again, a full physical exam as much as we can.

Tasha McNerney:
These little guys are really dependent on heart rate in order to maintain that cardiac output. Remember, we need cardiac output to be maintained because our blood pressure is dependent on cardiac output. So, for these little guys, they kind of come in with that high heart rate. The whole thing during anesthesia is I want to keep that heart rate as close to normal or even a little bit higher as possible because as my heart rate gets lower and lower, or the patient gets bradycardic, that’s going to drop my cardiac output. The reason we care about that is that cardiac output is going to influence oxygen getting delivered to the things that we care about, the liver, the kidneys, the brain, et cetera.

Tasha McNerney:
Also with these guys, the pulmonary reserve is limited, so they can get hypoxic faster. So, these guys, definitely always make sure if you’re giving them any kind of drugs or sedative, it’s in the presence of oxygen, you have supplies ready to go to intubate them. Now, these guys are ones that I’ll tell you sometimes I use them in birds and reptiles, but for these really tiny little guys, I might choose an uncuffed endotracheal tube, an appropriately-fitting uncuffed endotracheal tube, so that way I don’t have to put a tiny tube in and then push that reservoir cuff on the end of a tracheal tube, because too much pressure on these little guys can cause some tissue necrosis in that trachea.

Tasha McNerney:
So, these, I have a selected of not only cuffed, but also uncuffed tubes for them as well. Now, these guys also, everyone’s underdeveloped, so that’s just what you got to on. Their sympathetic nervous system is also underdeveloped. So, that means that drugs that are going to work on the sympathetic nervous system, so again, things like ketamine, telazol, that kind of stuff, those drugs usually will get a sympathetic response, and we see an increase in heart rate and a little bit of increase in cardiac output with them, but we don’t ketamine and tiletamine in these really tiny patients. Again, because that sympathetic nervous system is underdeveloped, they don’t have the same response that an adult or an animal of maturity would have.

Tasha McNerney:
Also, these animals get very hypoglycemic fast. So, before I give any drugs, I want to check a BG and make sure that we’re in range, and I want to be ready to supplement with dextrose as needed. Again, we’re constantly checking EGs. Now, with a cuterebra patient, hopefully they’re not going to be under anesthesia or sedation for a long period of time, but certainly, I have done some amputations on very tiny, tiny little guys where they might be under anesthesia for up to an hour, and we’re every 15 minutes checking BGs on them. Also with these guys, thermoregulation is going to be a big one.

Tasha McNerney:
So, before you get this patient sedation, you want to plan on how are we going to keep them warm, whether that’s a Bair Hugger or whether that is just covering the body in bubble wrap and providing either active or passive warming. You want to have a plan for warming because in these little guys, that larger surface area to body weight ratio means that they’re going to lose heat much faster, and then if you intubate them, you almost always are putting these little guys on a non-rebreather, and remember that that high flow of oxygen from a non-rebreather, it is going to contribute to them getting colder faster as well. So, just be ready with a plan for thermoregulation.

Tasha McNerney:
If you have the opportunity to… If it’s a planned procedure, you know they’re going to come in, again, with the hypoglycemia and et cetera, the fasting recommendations for these guys are no more than three hours, so we want to make sure that they have not been… These are not patients we fast for eight hours or even overnight. We really don’t want to do fasting with these guys. Once we have all of our stuff together, you have your stuff for intubation, you have your oxygen, you know your heat support protocol, all that, if you want to talk about drugs, again, I already mentioned that I probably would stay away from things like ketamine, tiletamine, which is a component of telazol, but maybe I’m going to go with an opioid, and usually the [inaudible 00:10:24] opioids, whatever is your opioid du jour at your clinic, maybe you are a hydro clinic, maybe you are a methadone clinic, again, I always say dealer’s choice when it comes to new opioids.

Tasha McNerney:
I am equal opportunity opioid, so if you want to do hydro or methadone, whatever it is, the nice thing is that it’s reversible, so we just tend to go a little bit lower on our dose, but opioids are pretty safe for these guys. Now, if you give a big dose or you’re giving fentanyl IV, you might see a reduction in heart rate, and again, these guys are really dependent on heart rate, so I always have a dose of anticholinergic drawn up and ready to go for these patients. In some cases, especially in the neonatal, not in this case, but a really tiny brachycephalic patient, because of their high vagal tone, this is the one area of patients where I am going to put glycopyrrolate into their premed to offset any of that reduction in heart rate, and therefore, reduction in cardiac output. So, I always have a dose of anticholinergic.

Tasha McNerney:
Now, some clinics don’t have glycopyrrolate. You might have atropine. So, again, whatever you have at your clinic, just make sure you have a dose of anticholinergic drawn up and ready to go, not over there on a shelf, in the same room with you, but actually calculated, drawn up, ready to go with these. Then the next thing that we consider is if we’re going to put a catheter, if we’re going to intubate them, you can give them an opioid and then a local anesthetic, just a little bit of lidocaine just around the area of the cuterebra to cut those pain signals going to the brain for when you actually have to open and widen it and pop, pull that cuterebra out.

Tasha McNerney:
So, I like a combination of opioids and local anesthetics, definitely some flow by oxygen and ready to intubate as needed. Again, the timing of these procedures, you could make the case that intubation in itself, because it has complications, this might not be warranted, but certainly, if you were dealing with something like an amputation or a longer procedure, you would want to intubate these patients to have control of your airway. If you needed something a little bit more, there’s always alfaxalone, which you could give a small dose of alfaxalone IM. Now, again, with alfaxalone you’re not providing any pain control, and alfaxalone is one of those drugs that if you do use it IM, which is off label in the US, but on label in New Zealand and Australia, if you’re using alfaxalone IM, just remember alfaxalone doesn’t play nice by itself.

Tasha McNerney:
Alfaxalone needs a buddy. It needs a friend. Now, that friend can be an opioid. That friend can be something like midazolam, but alfaxalone doesn’t go well by itself. When we use alfaxalone IM by itself, you tend to see nystagmus, muscle tremors, which some people mistake for seizures, et cetera. So, that’s why I always say make sure if you’re giving alfaxalone, you’re pairing it with something else, and in this case we would be. We’d be giving this kitten an opioid of some sort. Does that all sound good?

Dr. Andy Roark:
That all sounds good. So, there’s a lot there. That all matches up. I’m frantically taking notes over here. Yeah, that’s really helpful.

Dr. Andy Roark:
Hey, everybody. I’m just jumping in with two lightning-fast updates. Number one, if you have not gotten signed up for the Get Sh*t Done Shorthanded Virtual Conference in October, it’s October 6th through the 8th, you need to do that. If you are feeling overwhelmed in your practice and you want things to go smoother and faster, if you do not want to watch webinars, you want to actually talk about your practice. You want to do some discussion groups, you want to do some workshops where you actually make things and work on things and ask questions as we go along, and have round table discussions and things like that, that’s really going to energize you and help you figure out actionable solutions that you can immediately put into practice to make your life simpler and more relaxed, I got you covered, buddy, but you don’t want to miss it.

Dr. Andy Roark:
Go ahead and get registered. Mark yourself off at the clinic for the time so that you can be here and be present and really take advantage of this. I don’t want it to sneak up on you. I know October seems like a long way away. It’s not. But go ahead. I’m going to put a link down below, and then when registration opens, we’ll let you know it’s open and you can grab your spot. But you do not want it to sneak up on you. Check out our Get Sh*t Done Shorthanded Conference. It’s going to be a great one. The second thing I’m going to tall you about is Banfield. Thank you to Banfield Pet Hospital for making transcripts of this podcast available. You can you find them at drandyroark.com. They are totally free and open to the public, and Banfield supports this to increase accessibility and inclusion in our profession. It’s a wonderful thing that they do. Guys, that’s all I got. Let’s get back into this episode.

Dr. Andy Roark:
Do you have a thermoregulation preference for an itty-bitty like this? Is there something that you think is more effective with something so tiny? I imagine this little speck disappearing underneath a Bair Hugger. You’re kind of hovering over top of the kitten because there’s just so little there. Yeah. Do you have… Give me some advice. Even if it’s just… You said dealer’s choice. Even if it’s personal preference, what do you like for helping maintain body temperature in itty-bitties?

Tasha McNerney:
Yeah. These really tiny ones, I do still think that an active warming as a HotDog or a Bair Hugger or a warm water blanket is the way to go.

Dr. Andy Roark:
Okay.

Tasha McNerney:
Certainly, as you said, we can’t use a regular… Even the small size Bair Hugger blanket this kitten is going to disappear under, but we can… A lot of people, if you have Bair Hugger blankets in your practice, they come with these little plastic inserts, and most of the time people just throw them away. I’m going to tell you, don’t throw them away. Okay? You can actually use the plastic sticky things that come in with it. They come with the Bair Hugger so that you can put the plastic around, and they actually help to seal in the juices as far as the heat goes. But again, most people just throw them away. Don’t. Keep them around because you can stick them longways over your patient, and then you can just finesse the Bair Hugger output or the warm air output underneath this plastic.

Tasha McNerney:
Again, you could use something like bubble wrap as well, and then provide the Bair Hugger underneath that. But usually, I have it on each side. So, I might have a warm water blanket, warm water circulating blanket underneath the patient, and then I might have the Bair Hugger or even a HotDog around it. I will say I’m a fan of the HotDog. What I like about it is that unlike the Bair Hugger, you don’t have to worry about things blowing around your surgical site, and the nice thing is for these really tiny patients, the HotDog does actually make a very tiny size HotDog blanket. It is adorable if you have the chance to see it, but it’s made for hamsters and gerbils, so it’s really tiny, and it will wrap around the patient to provide active warming. So, if you have a HotDog in your practice already and you are dealing with small cats and kittens, I would say invest in one of these because it is really nice to wrap them around, and again, it’s just freaking cute.

Dr. Andy Roark:
All right. I feel good about that. So, I’m feeling good about all of this, honestly. So, up to our procedure, this all makes sense. I can lay all this stuff down. I have everything in the clinic. This is perfect. This is really, really great. Do you have any advice on analgesia post-procedure?

Tasha McNerney:
Yeah. So, for these guys, analgesia post-procedure, hopefully… Here’s the thing. Unfortunately, what you’re going to be dealing with is some inflammation, and we just don’t have, or at least I would say that I would be a little bit uncomfortable giving something that’s four weeks of age a nonsteroidal antiinflammatory. So, with this patient you could consider things like oral transmucosal buprenorphine for analgesia. If you have gabapentin formulated, please note that I’m not saying that gabapentin will be the sole analgesic, but gabapentin can help these patients feel better, provide a little bit of sedation, et cetera. Also, for inflammation, if you have in your practice and you are able to do a session or two before the patient leaves, something like a low-level laser therapy on the antiinflammatory setting is a nice, again, non-pharma adjunct for these patients.

Tasha McNerney:
But really, cats are just amazing in how fast they can bounce back. I think the biggest thing with these little guys is that as long as you’re maintaining their heart rate and their cardiac output, again, which you know what, just means no dexmedetomidine. I know you’re all tempted, and it’s my favorite drug, but in these guys we want to make sure we avoid dexmedetomidine or something like that. But for post, usually these heal up pretty quickly. I like to do laser therapy gabapentin if you can get it compounded so that your dosing would be accurate. It’d be hard to give this little tiny kitten a tablet or a quarter or an eighth of a tablet.

Dr. Andy Roark:
Yeah, yeah. At some point, you’re just kind of scraping powder. Yeah.

Tasha McNerney:
Yes.

Dr. Andy Roark:
That’s no good. All right, perfect. Man, that’s super great. Tasha McNerney, you are amazing. Thank you so, so, so much for being here. Where can people find you online? Where can they learn more if they like to geek out about anesthesia?

Tasha McNerney:
Yeah. So, if you are on Facebook, we run the Veterinary Anesthesia Nerds Facebook group. I always tell people that if you’re not on Facebook, this is not the reason to get on Facebook. If you’ve avoided Facebook this long, I applaud you. You’re probably living the life, man. So, we are on Facebook. We also are going to be having a conference within a conference this year. So, if you are going to or if you’re thinking about heading to Fetch in San Diego in December, the anesthesia nerds are going to be running their conference inside of the Fetch Conference. So, we’re going to have two days of nothing but anesthesia and pain management. We’re doing a regional nerve block wet lab to teach people some more advance ultrasound-guided regional nerve block techniques, and we’re going to do basic nerve blocks as well, but all things nerve block. So, that’s going to be coming out, our links to register for that, pretty soon.

Dr. Andy Roark:
That’s outstanding. Awesome, awesome. Thanks anything for being here. Guys, take care of yourselves. Have a wonderful week, and I’ll talk to you next week.

Tasha McNerney:
Thanks.

Dr. Andy Roark:
That’s our show. That’s what I got for you, gang. I hope you enjoyed it. I hope you got something out of it. If you’re watching on YouTube, hit that subscribe button. If you are listening on the podcast, leave us a review wherever you get podcasts. Tell your friends. That’s how people find out about the show. I really appreciate it. Really appreciate your help. Gang, take care of yourselves. I’ll talk to you soon.

Filed Under: Podcast Tagged With: Medicine

Feline Lower Urinary Tract Disease (HDYTT)

September 25, 2022 by Andy Roark DVM MS

Dr. Lauren Pagliughi joins Dr. Andy Roark to discuss a case that is oh-so-common in veterinary medicine, and oh-so-likely to end badly for feline patients! They are talking about Feline Lower Urinary Tract Disease (FLUTD). They discuss the importance of environmental questions for pet owners, diagnostics (including radiographs), and responsible approaches to treatment in regrade to antibiotic use. Let’s get into it!

Cone Of Shame Veterinary Podcast · COS – 162 – Feline Lower Urinary Tract Disease (HDYTT)
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This episode has been made possible ad-free by Purina Pro Plan Veterinary Diets!

LINKS

Purina Pro Plan Veterinary Diets: https://www.purinaproplanvets.com/

Indoor Pet Initiative (cats): https://indoorpet.osu.edu/cats

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/store/

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Lauren Pagliughi attended Rutgers University for her bachelors of arts and obtained her veterinary degree from Colorado State University. Upon graduation, she completed an internship in Small Animal Medicine and Surgery at Oradell Animal Hospital in NJ. She then joined Absecon Veterinary Hospital, a large general practice in NJ, before joining the Purina family in 2013.

Lauren currently resides in Linwood, NJ serving as a veterinary communications manager for Nestlé Purina Petcare. Spreading passion for advanced nutrition, she supports veterinary teaching hospitals throughout the country and provides technical support for Purina’s sales consultants. She continues to practice as a relief veterinarian in South Jersey. In addition to nutrition, Lauren has a key interest in small animal surgery.

Lauren spends all of her free time with her twin boys Zachary and Felix, and her daughter, Greta. Lauren also enjoys being outdoors mountain biking, surfing, cycling and snowboarding with her children and her husband, Michael. She loves spoiling her lab, Dottie Lou, and her two cats, Cecilia and Daniella. She has a passion for sustainability and helping others to make “green” choices.

Dr. Pagliughi went tandem sky diving 3 times when she was 19 years old in hopes to become certified – that did not happen! She has a passion for high intensity sports, like Mountain Biking and Snowboarding. She has a dream of moving to Costa Rica one day.


EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast, I am your host, Dr. Andy Roark. Guys, I’ve got a great one today, we are talking about kitty cats being outside the litter box. That’s right, it’s FIC, that’s feline idiopathic cystitis or FLUTD, which is feline lower urinary tract disease. We use both of these terms in the podcast and we use them interchangeably so I just wanted to lay it down up front. I am talking to my friend, the one and only Dr. Lauren Pagliughi and she is walking me through what do we do about these cats. It is a fascinating episode, we talk a lot of behavior, we talk about great questions to ask the pet owners, we talk about setting expectations, we talk about treatment, we talk about nutritional therapy and we talk a lot about diagnostics and just really work these cases up in a very rewarding way. Guys, I hope you will enjoy this episode, let’s get into it. Oh, and this episode is made possible, ad free by Purina Pro Plan Veterinary Diets.

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. Lauren Pagliughi, thank you for being here.

Dr. Lauren Pagliughi:
Thanks for having me, Andy. I’m excited to talk about urinary health.

Dr. Andy Roark:
Awesome. Well, I am glad that you’re here. You are a practicing veterinarian, you do some emergency work, you do community work, volunteer work even, you are also a Vet Communications Manager at Purina, which means that you are a nutrition educator in a lot of ways. Yeah. And we were talking just a while ago, you are an avid cyclist and mountain bike as well with three kids, so you stay busy.

Dr. Lauren Pagliughi:
I stay very busy.

Dr. Andy Roark:
I wanted to talk to you today about something that is squarely in your wheelhouse. It is a case that I see a lot and I always like to check myself and make sure that I am doing these cases the way that I should. I’m going to be honest about something that I struggle with as we talk through this. But I want to get your insight on a case that I have, are you ready?

Dr. Lauren Pagliughi:
Absolutely.

Dr. Andy Roark:
Okay. I have a six year old female spayed domestic shorthair named Penelope in room two. She is in for accidents in the house. She is peeing on the couch and peeing on the blankets and the owners are baffled and very frustrated. Now they have had Penelope for a long time, they’ve had her since she was a kitten, this is not a normal behavior for her so I brought her straight in and looked at this and went for a medical examination and evaluation of her and did a sterile cysto and a urinalysis, as well as some blood work.

Dr. Andy Roark:
I don’t see anything of note on the blood work, which is good. I do on her cysto urinalysis, see a lot of blood and some crystals. And so I am looking at this cat and immediately I say, “I don’t see any bacteria.” I expect this is lower urinary tract disease or FIC, but I worry about, is this an infection that I’m missing? Is there something else going on? I just want to work this case up in the best way possible because it’s a common case and I want to get it right. Let me turn this over to you and just say, starting out right here, looking at this case, how do you, Lauren, treat this?

Dr. Lauren Pagliughi:
Great question. So these are common cases that we see in practice and they are frustrating. They’re right up there with the derm cases that we see on a regular basis because they’re often chronic in nature. A lot of the times a cat that presents for inappropriate urination will present again for the same issue because of some risk factors they might have. So I usually backpedal a little bit and just try to empathize with the owners. I don’t know if you’ve ever had a pet urinate in your house somewhere that is difficult to clean. I have a neighbor actually who is going through this right now with her cat, it urinated on her couch and it essentially ruins the furniture. And you love your pet, but believe it or not, this is one of the most common reasons that cats are surrendered to animal shelters. So it’s a big problem, not just for the owner, but for the pet as well and for their quality of life.

Dr. Lauren Pagliughi:
And I think there’s this misconception that there’s always a behavioral component. Sometimes there is a behavioral component, but often together with the owners, we can come to some type of solution. So I think that off the bat, it’s really important to discuss with your owner and to help them understand that how they’re feeling and how frustrated they are and that you want to help them find a solution for their pet and for their own household so their own household isn’t getting ruined at the same time. I think also even before going right into diagnostics, which is absolutely something that needs to be done in all of these cases, I think trying to determine if there is a behavioral component or if it’s more of a medical problem that’s causing this inappropriate urination. So getting some more information about the environment, about how many cats are living at home, about just the temperament of that cat in general.

Dr. Lauren Pagliughi:
So is Penelope what the owner would describe as a scaredy-cat? I have a scaredy-cat. I have two cats in my office right now sleeping, two geriatric little old ladies and one is scared of her own shadow and I wouldn’t be surprised if she was a FLUTD cat at some point in her life. Thank God she isn’t. But knowing that can help you understand if they fall into the category of cats that are at risk for lower urinary tract signs, which is the new name for FLUTD. And also, is the cat obese? What is the environment like at home in terms of litter box maintenance? Are there a bunch of kids running around? I have three little kids, it’s a stressful environment for cats in my household as well. So understanding all of that prior to jumping into diagnostics is really helpful because you’re going to need all that information anyway.

Dr. Lauren Pagliughi:
You did the right thing first and foremost in getting the urinalysis, it’s really hard to make this diagnosis without having all the different pieces of the puzzle. And I say the pieces of the puzzle because lower urinary tract signs or FLUTD are multifactorial. So all that environmental stuff we just talked about, underlying medical conditions, a potential stones or urinary tract infection, things that we can treat will be hopefully found out through diagnostics and then just individual response. So every cat’s going to be different and the same treatment plan might not work for every single cat. And the owners play a really big role in the treatment of cats with FIC, of cats with lower urinary tract signs of any sort.

Dr. Lauren Pagliughi:
And I can pick on my own self, early on as a vet I probably didn’t involve the owners as much as I needed to. They play a huge role because they’re the ones managing them on a day to day basis. As vets all we can do is prescribe food and maybe medication to help them if it is a medical cause of the signs that we’re seeing. But beyond that, we’re not doing a whole heck of a lot. So it’s really up to the owner to be on the same page, right there with us in part of that treatment plan to really get down to the bottom of what will help to reduce these signs and hopefully eliminate them and make that pet feel better.

Dr. Andy Roark:
Talk to me a little bit about what it means to partner with the owner at this phase? And you say we didn’t include them as much as you wished that you had, help me understand what that looks like in your mind? What you do differently now than you did earlier in your career?

Dr. Lauren Pagliughi:
Yeah. So I think the longer I’ve been a vet, I lost to my own dogs last summer and just experiencing pet ownership myself. When you’re a brand new vet, you may have had your pets growing up, you may have a young cat or young dog, that was me for a long time. And I think experiencing different ailments in your own pets helps you empathize a lot more so with pet owners. If you have, God forbid, a dog that seizures, you’re going to really empathize with someone whose pet suffers from idiopathic epilepsy. Or if you have a cat with inappropriate urination, you’re really going to empathize with these owners that come in. So regardless of if you’ve gone through that, I think it’s important to try to find that empathy first. And that really helps with that communication, they’re going to trust you more because you understand how they’re feeling, you’re validating what they’re going through.

Dr. Lauren Pagliughi:
And then once you’re on that same page together, I think it’s getting that commitment from the owner of, “Hey, Penelope’s mom, I want to help Penelope. And these are the tests that we’re going to do to help figure out if there’s something medically that I, as your vet, can treat. And here’s all the things that we’re going to do together and I’m going to help you do at home so that we can address all these other factors that might be increasing the risk of Penelope having FLUTD or having potentially FIC, whatever diagnosis we get to over the course of examining her and doing all of her test. But Penelope’s mom, if I can’t get you on the same page, we’re going to have a really hard time getting her symptoms to go away and we’re going to have a really hard time getting her to feel better and having good quality of life and we’re going to have a really hard time preventing your furniture from getting peed on.”

Dr. Lauren Pagliughi:
So I think it’s getting that buy-in so important. And we can say that for so many different diseases that we treat in veterinary medicine. I always think of doing an elimination diet trial and using a hypoallergenic diet or an elemental diet that you really need that buy-in from the owner, you cannot just send that bag home, you’ve got to make sure that they can absolutely commit, 110%. And the same goes for FLUTD. And I’ll talk about, if we get some time on this podcast, about some good resources that owners can use to help to modify that environment at home, to really reduce stress in these guys.

Dr. Andy Roark:
Yeah, definitely. Let’s jump back to the diagnostic process here. So I really like your behavioral, environmental approach asking about stressors, things like that, that totally makes sense. I said, “Blood work looks good, I’m seeing a lot of blood and some crystals and things in the urine.” For you, when you look at this, do you ever have a question about this being a urinary tract infection or the benefit of antibiotics to it? That’s the thing I said at the beginning, I said, I wrestle with this. I’ll be honest, I want to be a good steward of antibiotics, I also struggle and go, “Well, what if I’m wrong and I tell them we’re going to approach this to FIC, but there’s a bacterial infection?” Do you ever have that concern and how much confidence do you have as you approach these?

Dr. Lauren Pagliughi:
So the good thing is in Penelope’s case, you already got a urinalysis and you got it via cysto. So you have urine that you can hold aside and you can send off for culture, if you decide you want to go that route. The fact of the matter is that young and adult cats have a very low risk of a urinary tract infection, it’s 1% to 2% of cats. If they become more geriatric and have concurrent diseases like diabetes or renal disease, then their likelihood of having UTI goes up a little bit. But you already mentioned that Penelope is six years old, she’s otherwise healthy, her blood work was all normal so the likelihood of her having a UTI is very low.

Dr. Lauren Pagliughi:
So the problem with just… And I’ve done this, again, I will raise my hand and slap my own hand, I’ve given many a cat coming in because you feel like these owners come in and you want to help them and you don’t want to send them home with nothing, you want to try something, whether it be pain medication or antibiotics. And then sometimes you give this stuff and then you’re like, “Did it help?” Maybe that is what helped and so you go down this road of doing something that probably is doing more harm than we really realize.

Dr. Lauren Pagliughi:
So we know that some of these longing-acting antibiotics like Convenia, when they’re necessary, they’re absolutely great. But when they’re not necessary, they’re probably wiping out a lot of the important micro flora in the GI tract of these guys, which can impact their immune system and lead to dysbiosis down the road. And we don’t want to do that unless we have a really good reason to give antibiotics. So I say, when in doubt, do not give antibiotics and if you are really suspicious of a UTI, then send off a culture. Absolutely, there’s no harm in doing that and then you’ll know for sure.

Dr. Andy Roark:
Okay. That I completely makes sense to me. I like that a lot. I like the idea of talking about the culture just to cover our bases. Then I still feel like I’m doing things. You mentioned giving them something like pain management medications. And I do think that, that’s important and honestly, that scratches a lot of itch for me, as far as feeling like I need to do something and I want to help this cat right now. Can you talk a little bit about pain management, supplemental approaches to this? And so we’ve moved in and we have our culture and we can confirm that there’s no infection and things like that. And so it seems like we’re moving down the course of treating this as a FLUTD cat, let’s go ahead and start talking about comfort first, how do you approach that and what do you communicate to the owners?

Dr. Lauren Pagliughi:
So the research is iffy out there as to whether or not cats really do better on pain therapy or not in these cases. So some vets will feel really comfortable using something like Buprenorphine. You want to be pretty careful with NSAIDs and make sure that there’s no renal insufficiency or anything like that because we don’t want to be causing any renal issues with pain medication. Really my go-to is trying to get that urine really dilute and trying to get them to actually pee more so that we can continue to flush that bladder and reduce stress by doing this multimodal environmental modification that the owner is super involved in. So doing things to reduce stress and as we reduce stress, then a lot of the times these cats overall feel better. But pain, typically it is the veterinarian’s choice of what they feel comfortable to use safely in their patients. But Buprenorphine’s pretty well tolerated by cats and pretty rare contraindications to using a drug like that, but just be careful with the NSAIDs in these guys.

Dr. Andy Roark:
Okay. Let’s talk about stress reduction. So we started off with environmental questions and we talked about things that are possibly affecting Penelope at home, things like that. Maybe they have some, they don’t, but we’re going to talk about alleviating that stress and then where do you go from there?

Dr. Lauren Pagliughi:
Yeah. So we could talk about different supplements, Calming Care is a probiotic that can help reduce anxiety in cats. But I think before going down that road of considering supplementation or anxiolytics, really diving into that environment. It’s no different than a person who might need to start a medication to help with their stress and what’s going on in their lives. But if all those stressors are still there all the time and you’re doing nothing to modify your environment, it’s going to be a lot harder to feel better. It’s no different for our pets. So there’s a good website through Ohio State called the Indoor Pet Initiative, you could just Google it and you can find it very easily and there’s some really great resources on there. They follow the N+1 rule with essentially everything that is in the cat’s life. So if you have two cats, you should have three to four litter boxes and you should have multiple places for them to eat and drink and multiple places for them to perch or lay around or wherever they’re comfortable.

Dr. Lauren Pagliughi:
And most households are not set up like that for their cat. So those are some really easy things that owners can do to modify their environment and to make the environment less stressful for that cat. Also, trying to identify the stressors in the house. So if you have a skittish cat, what is causing that stress right now? I mentioned earlier that my cat share my office with me and that’s for several different reasons. They did not grow up around my children, my children came later. They do not like my puppy, they are stressed as can be when they are not in my office. They prefer to have this as their space, they have their little cat tree over in the corner and they can come and go as they please out of the room, but nobody else comes in here except for me.

Dr. Lauren Pagliughi:
So not every cat is going to be a kid person, not every cat… Or kid cat, I should say. So understanding your pet and trying to adapt more to them, I mean, they are cats, they rule the world and rather than trying to have them adapt to us. And I think that’s really important to think about. Other things that can help to reduce stress is pheromones so Feliway diffusers or Feliway spray can help to reduce stress in some cats so that’s always a good thing to think about.

Dr. Lauren Pagliughi:
And then, like I mentioned, once we have that environmental component really nailed down, then maybe considering things like Zylkene or Calming Care or potentially some anxiolytics, if you want to go down that road. But I think addressing the environment is so important and I would say maybe the most important part of the puzzle, that and diet, to really address these guys. And I think that part’s often missing or the owners aren’t realizing what an important role they play and think that there might be just a magic diet or a magic pill that will take care of all the problems their cat’s having, but they really have to be invested in getting their pet to feel better.

Dr. Andy Roark:
Yeah, that’s really interesting. I don’t think I’ve really processed how much getting the pet owner on board with that part of it probably means. So that’s something I’m going to have to think a little bit about as far as, have I been impressing this on pet owners enough? And probably not. So that all makes sense to me and it tracks along. Walk me through your approach from a treatment standpoint? Let’s just say that we have a spouse who’s going, “Look, I need this cat to stop peeing on my [inaudible 00:18:34] now.” And I think we’ve all seen those cases where this cat is one person’s cat and the other person in the house tolerates the cat and now they are really having a hard time. That’s real stress that people have to manage.

Dr. Andy Roark:
Walk me through your steps and even a timeline of what do you generally start out with? When do you have them come back or call you with updates? Help me go through your steps? And I want to understand timelines too because I don’t want to jump in and it’s easy to do everything at once and go, “We’re going to do Calming Care and we’re going to do diet and we’re going to do a new water bowl and a fountain that gets them to drink.” And you can do all the things at once and it can be really overwhelming, but you can also not take this seriously enough and then there’s a lot of tension at home. And this is the number one reason that cats end up in shelters and that sticks with me and haunts me and I go, “I really don’t want to not seem motivated here.” So how do you balance those things and what does your timeline look like?

Dr. Lauren Pagliughi:
Gosh, timeline is going to be so individual, Andy, that’s a hard one because every cat’s going to be so different. And I mean, I always like to be positive, but if you have a cat that’s coming in, that’s urinating inappropriately and it’s one of 10 cats in a household, gosh, I mean those are really challenging cases. And sometimes we don’t get to the bottom of those, sometimes we can’t find a solution in every single situation. But again, I think opening that line of communication and setting realistic expectations are so important with our owners, we need to set realistic expectations. The cat, Penelope might urinate on the couch again before we get to the bottom of this and we might not stop it entirely, but we’re going to do our darnedest to try. And we’re going to see if we can find a solution, whether it be medical or behavioral or environmental or whatever it may be so that we can stop her from doing this.

Dr. Lauren Pagliughi:
But again, I think we need that buy-in and we need that realistic expectation. And timelines make me nervous because giving an owner a timeline and we can’t predict exactly how every patient’s going to respond. So giving a timeline to an owner I think we’re going to be shooting ourself in our foot if we don’t stick to that timeline. So I think if we backtrack a little, we’ve had this great discussion with Penelope’s mom, we get her on board, we talk to her maybe about some solutions to trying to get that urine smell out of the couch or maybe we just cover it for now or come up with some solutions. Maybe the cat is happy, confined to one room where she could put some perches in and a bunch of litter box and keep her away from some of the other things that stress her out.

Dr. Lauren Pagliughi:
A lot of the times people think that cats won’t like that, some really do, some actually like that change of environment. Some cats want to be able to go outside, I mean, sometimes that is a big stressor for them, maybe they started as an indoor, outdoor cat or an outdoor cat and then they got moved in. So really digging down as a vet to try to understand what changed in that cat’s life or what is happening that is creating stress for that cat, that’s making this cat now do this, if that’s the cause. So then as you mentioned, you did blood work, which is really important because there’s lots of things that can cause cats to urinate more or inappropriately. So we want to make sure that we don’t have any renal insufficiency or anything else going on, diabetes. And then the analysis, you mentioned that there were a lot of crystals and a lot of blood.

Dr. Lauren Pagliughi:
So hematuria is pretty commonly seen with FIC cats. So idiopathic cystitis, our favorite word is vets for when we don’t know what causes something. So just unknown inflammation in the bladder, blood is often what we see there. But it is important to realize too, that when we do a cysto or we palpate the bladder, we can cause iatrogenic hematuria. So sometimes just spontaneous nutrition can help us to know if that is real or not. So asking the owner if they see blood when they’re looking at the couch or wherever the cat’s urinating inappropriately or in the litter box. And then the crystals I do want to mention, because I think crystals haunt veterinarians. They see them, they want to treat them, they don’t feel right to see them on a urinalysis, but they can be very normal. And there’s a lot of different studies looking at disillusion with some Purina diets where normal cats had crystals and crystals were not very predictive of stone type.

Dr. Lauren Pagliughi:
There’s an interesting study that showed, I think, 28% of urine samples form crystals just from sitting out on the counter or going in the refrigerator. So just forming outside of the body in the urine. So I like to use the pun, “Take it with a grain salt.” Don’t fixate in on the Crystalluria. On the flip side, it’s really important to think about taking a radiograph as well. The number two cause of lower urinary tract signs in cats are stones. And we so often skip that because FIC is the most common, but stones are still common enough that shooting two of you radiographs of the abdomen to look for stones is super important. And it’s not enough to just do an ultrasound because you can miss things on an ultrasound, especially urethral disease, you can miss with an abdominal ultrasound.

Dr. Lauren Pagliughi:
So x-rays are so easy to do and most stones that we see in cats are going to be radio-peg and you’re going to see them on there. And that’s going to be a treatable disease, whether by surgery or with disillusion, if it’s a Struvite Stone. Then once we have all that information, we talked about antibiotics, I wouldn’t do antibiotics. We talked about pain controls, the cat seems uncomfortable, the cat’s meowing out, crying out, it seems to have strange area. Yeah, I think pain therapy is important to consider, lots of different modalities for pain therapy so whatever floats your boat there is a bet. And then diet, gosh, we saved the best for last, diet’s super important. So multimodal environmental modification and diet really, in my opinion, are the two most important things that we could potentially do to help these guys.

Dr. Andy Roark:
That makes a ton of sense. Help me set expectations for the pet owners. So when they come in and this is very individualistic and I don’t really know how long it’s going to take to see resolution of signs and that really depends a lot on how much of an impact that can make on the cat’s stress and things like that. How do you talk to pet owners about that? When they say, “When is this going to get better?” What language do you use?

Dr. Lauren Pagliughi:
Yeah. Gosh, it’s really important to stress that it’s so individual and that praising them and giving them kudos for being there, for helping their pet, helping them understand that Penelope, in this example, is not doing it out of spite, I hate when owners say that. Our pets are funny and they have funny little personality quirks, but I don’t think they’re intelligent enough to do it out of spite. So helping them to understand that there’s a medical reason or behavioral reason that your cat’s doing this and that can also help them to be a little bit less frustrated and a little bit more empathetic to their own pet’s problem. And then beyond that, I try not to really, again, set that timeline per se, I try to get those treatments on board.

Dr. Lauren Pagliughi:
So getting them fully on board with multimodal environmental enrichment, getting that pheromone spray, adding litter boxes, getting them to drink more. So a lot of different ways to get them to drink more, we can do a canned urinary diet, they can add in a hydration supplement like Hydra Care, they can try water fountains, extra water bowls around the house, adding water to the dry food. And then getting them on board with a therapeutic urinary diet. So urinary diets, namely they’re formulated to get the cat to drink more water, to increase urine volume. And as we increase urine volume, they urinate more frequently and they can flush out some of these inflammatory mediators that are in their bladder and help to reduce their symptoms.

Dr. Andy Roark:
Awesome. That’s super helpful. Are there any final pearls of wisdom that you would put forward in approaching these cases? Are there any common pitfalls that you see people falling into, any tricks that are commonly missed?

Dr. Lauren Pagliughi:
Yeah, absolutely. I think that on one side inappropriately treating for UTIs that aren’t really there, treating Crystalluria that’s not causing symptoms, crystals don’t typically cause symptoms. Those would be the cat that doesn’t need to be treated like a FLUTD cat. Then you have your true FLUTD cat that again, I think the common pitfalls is not getting the owner on board. We need to get the owner on board to get these cats to resolve, to get these cats to feel better and to stop urinating appropriately. And getting the buy-in on a diet and getting the buy-in on what they need to do and change at home, I think is most important. And then checking in, I think you mentioned timeline a couple of times and I know that owners want to know that there’s a light at the end of the tunnel and that’s where keeping that open line of communication can really help.

Dr. Lauren Pagliughi:
Checking in with them on a weekly basis, “How’s Penelope be doing this week? Let’s bring her back in a few weeks and check a urinalysis and see if her urine has less blood or is a little bit more dilute or whatever it may be.” Or maybe we don’t do that, maybe we don’t stress her out by bringing her in and we just monitor some of those clinical signs at home and we let the owner know what to look for and how to manage that. So yeah, I think not treating what doesn’t need to be treated is really important, misuse of antibiotics is a pet peeve of mine, just treating crystals that aren’t a problem is a pet peeve. And then forgetting the importance of the owner’s role in the treatment of these cats and diet, we’ve got to get them on a urinary diet to really get that urinary environment so that these cats aren’t having as many issues.

Dr. Andy Roark:
What is your favorite resource or resources for people who want to learn more about FLUTD and managing FIC?

Dr. Lauren Pagliughi:
Sure. So the Purina Institute actually has some really good resources on Centre Square now. So Purina Institute is product-agnostic, you won’t find any product info on there, but there is a whole nutrition resource portion of the website now called Centre Square, it’s C-E-N-T-R-E. And if you just type in urinary in the little search bar, you’ll find a whole bunch of different articles and you can actually send those to your clients, you can email them and print them out. And these are written by veterinarians so it’s a really good reputable source. And then earlier I mentioned that Indoorpet.osu.edu, that is a really great resource for all that environmental enrichment and probably the most important thing that the owners can be doing at home. So there’re tons of resources on there that are really owner driven.

Dr. Andy Roark:
That’s fantastic. Awesome. I’ll put links to those in the show notes as well. Dr. Lauren Pagliughi, thank you for being here, I really appreciate your time.

Dr. Lauren Pagliughi:
My pleasure, Andy. Thanks for having me.

Dr. Andy Roark:
And that is our episode. Guys, I hope you enjoyed it, I hope you got something out of it. Thanks again to Dr. Lauren Pagliughi for being here, thanks to Purina Pro Plan Veterinary Supplements for making this episode possible. Guys, I hope to talk to you again soon. Be well.

Filed Under: Podcast Tagged With: Medicine

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