DrAndyRoark.com

Articles, Videos, & Training on Pets & Veterinary Medicine

Medicine

Are You Haunted By Negative Exploratories?

by

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

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

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

Wow, what an incredible email!

My reply was:

Hi Andreane,

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

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

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

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

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

Young Andreane had made the right decision after all.

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

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

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

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

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

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

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

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

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

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

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

Way to go Andreane!

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

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

Why Veterinary Professionals Are Medical Professionals Too

by

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

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

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

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

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

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

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

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

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

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

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

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

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

How My ER Visits Made Me a Better Vet

by

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Biggest Lie Vets Tell Themselves

by

Sometimes we tell ourselves lies to make life easier. We say things like, “I was walking in and out of exam rooms all day long. That counts as exercise,” or “There’s a ban on cellphones in the office, but everyone will understand that it doesn’t apply to me.” We kid ourselves to feel better, and it usually works.

To be fair, most of these tall tales are pretty harmless. However, some come back to bite us. There’s one particular lie that undermines the way we practice, communicate and provide patient care. It affects how we educate veterinarians and how we operate our clinics. Here’s the lie:

If we just tell average pet owners what’s best for their pets, they’ll do it.

This poodle knows you're lying to yourself

Isn’t this a wonderful idea? The problem is that, most of the time, it’s not true. And we know it.

Don’t get me wrong—this isn’t an attack on pet owners. I’m not saying people fail to follow doctors’ orders because they’re bad people or don’t love their pets. However, the question persists. Why?

The case of the crappy car owner

Sometimes in my lectures to veterinarians, I talk about the type of car owner I am. (Spoiler alert: I’m awful.) I love my car and use it extensively. I fully understand how much I depend on it and what a bind I would be in without it. Yet I don’t take very good care of it.

When it comes to fixing problems, I head right to the shop. I’m just not so great about the regular maintenance. The auto places always give me a list of what’s best for my car. It’s just that life/work/parenthood/finances/time keep getting in the way.

One day, after I made this confession in a talk, a feline practitioner shared her candid feedback with me. She said, “You know, you shouldn’t tell that story about your car.” I asked her why not. “Because it makes you look like one of those bad cat owners. The ones who never come in on time. You don’t want people to think that’s you.”

But here’s the thing: That is me. And it’s probably you. It’s almost all of us.

How many people have cars that are due for maintenance? How many of us are past due for a physical or a dental appointment? Is anyone putting off funding a retirement account or college fund?

Don't be THAT cat owner; visit your vet for annual checkups!

Listen, I’m not actually a bad cat owner. My pets receive great care not only because I’m a certifiable animal lover, but because I’m a trained veterinary professional. That’s not the case for the vast majority of our clients. They love their pets, but they also love their kids, their jobs, their hobbies, the idea of retirement and their teeth. Everyone has only so much money, time and energy, and no one thinks about pet health in their real lives as much as veterinary professionals do. Let’s face it: Most people are about as consistent at keeping up with pet care as I am with handling my car maintenance.

What we’ve gotten wrong—and how we can get it right

For years, I believed that if we just sat down and explained things to pet owners, they would do what was best for their pets. I’m sorry to say that I don’t believe this anymore. While this idea is comforting and makes it easier for us to shake it off when we make recommendations people decide not to follow, it’s simply not true. If we can come to grips with that, I think we can modify our approach in two ways to fix the problem:

1. Innovate to communicate. Often, our idea of client education is a single conversation between the pet owner and the veterinarian in the exam room. It’s an isolated interaction between a doctor and a person who may or may not be the patient’s decision maker. It’s also generally unstructured, brief and happening in front of a pet, a natural distraction. In short, it’s a frantic mess.

Educating pet owners in this fashion can yield only limited success. If we are going to successfully compel people to take specific actions, the messages we send must be clear, focused and repeated through multiple channels. We must help pet owners understand why we are making the recommendations and what they need to do. Conversation is one way to deliver these messages. Email, text messaging, videos, infographics, blog posts, interesting articles and smartphone apps are just a few ideas. Effective client communication is the single greatest opportunity for innovation in our profession today.

2. Stop abdicating our position. I have a friend who despises choosing a restaurant. In fact, it’s nearly impossible to get her to weigh in on any sort of dinner-related decision. The reason is that she doesn’t want to feel accountable if the place we visit is underwhelming. She takes comfort in always being able to say, “Well, it was your choice.” For a friend and a dinner decision, this is fine. But what if everyone approached choices this way?

Yes, we need to present pet owners with options, but we cannot relinquish our responsibility to guide their decisions. Too often, we say “Well, you could … ” and then present a multiple-choice scenario with options that may seem perfectly clear to us but are confusing to our clients. We feel good about putting the choice in their hands, but then we wonder why they so often default to the cheapest option. (The one element that’s not confusing in all of this? Price. You don’t need a medical degree to understand that part.)

Instead, what if we presented options in the context of making a strong recommendation? For example, we can use statements like, “Based on what we’ve discussed, the plan I’d recommend is … ” or simply, “To address your concerns, we need to … ” We can use these phrases and still give people options. However, they offer clear direction on how best to move forward and take advantage of our education, training and experience.

If we are acting ethically, listening to our clients and their needs and practicing a good standard of care, we should be able to give options while also making clear what path we believe will best serve the pet and owner. When we refuse to commit to any recommendation, we abdicate our position as a guide, consultant and doctor. I believe that also means we fail our clients.

Letting go of the biggest lie we tell ourselves in veterinary practice means we have to make some changes. We have to change how and what we communicate in order to increase the odds that pet owners will take the best action for their pets. In that way, we can ensure that when we tell clients what’s best, they’re hearing it and doing it. We can turn the lie into a truth.

I think I’m ready. Are you?